Care Team Referral

Background Information

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

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Care Team Referral

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Name

Phone number

Email address

Hall/Address

Does this person know you are submitting a CARE referral?

Please provide a detailed description of the concern using specific, concise, objective language (who, what, why, when, how)(Required) This field is required.

What steps have you taken so far to address this issue? (emailed/talked w/student, etc....)(Required) This field is required.

What is your desired resolution for this student?(Required) This field is required.

Is there any additional information that you would like to provide?(Required) This field is required.

Do you have any supporting documentation to provide? If yes, you can upload it prior to submitting the form below.

Yes No

You must make at least one selection.

Supporting Documentation

If you have any emails, photos, videos, etc., to share that would be helpful for the Team to have a complete picture of the nature of your concern, you may attach them to this report submission. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Does this person know you are submitting a CARE referral?

Supporting Documentation

Submission