Campus Assessment Response and Evaluation (C.A.R.E) Team Referral Form

Individual of Concern

Individual's First Name

Individual's Last Name

His/Her Email (if known)

His/Her Phone (if known)

What is the best way to contact this individual:EmailPhone

Reporter

Do you wish to remain anonymous to the C.A.R.E. Team?YesNo

Do you wish to remain anonymous to the individual you are referring?YesNo

Report

The members of the C.A.R.E. Team are available to the Manhattan School of Music community to accept notification and referrals of students, faculty, and staff who are in need of assistance and support. The purpose of this report is for you to be able to alert the Team of individuals whose actions and behaviors are of concern to you or the campus community. This report will be used to initiate assistance for the individual.

Please check off which apply to your concerns:

AcademicAdjustmentAlcohol/Drug AbuseDisrupting ClassroomEating IssuesFamily IssuesGrudgesHopelessnessSelf-InjuryStudent WritingsVerbal AggressionsWeaponsOther concerns

NOTE: If you have information about an MSM student who has been a victim of sexual harassment, gender-based harassment, sexual misconduct (including sexual assault), stalking, domestic violence or dating violence please use the Sexual Misconduct Report Form found here.

Have others shared with you that they are also concerned about this individual?YesNo

Would you be willing to share their names? If yes, please list them below:

Please comment on the concerning behavior below:

What, if anything, have you done to address this concern prior to the C.A.R.E. Team notification?

It is important to be true and correct in directing this information to the C.A.R.E. Team. Misrepresentation of information may result in disciplinary actions.

If you believe the individual or the community is in immediate danger, please contact the police department at 911.

I have read the information above and verify that the information I have provided is true and accurate to the best of my knowledge.

Clear

Info For

Campus Assessment Response and Evaluation (C.A.R.E) Team Referral Form

Campus Assessment Response and Evaluation (C.A.R.E.) Team Referral Form