Community Member Referral Form

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The Campus Assessment, Response, and Evaluation (CARE) Team provides proactive intervention for issues relating to the safety, physical and mental health, and well-being of our RMCAD faculty, staff, and students.

If you have concerns regarding the behavior of a community member, please complete the form below.

If the individual of concern is in a critical or emergency situation, immediately call 911.

Student/Staff Member of Concern Information

First Name: *

Last Name: *

Student ID Number:

Program:

Course Title (if relevant):

Modality:

Campus Student/Staff Member

Online Student/Staff Member

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Descriptive Information (If Applicable)

If identity of student/staff member is unknown, please provide descriptive information below:

Concern

Briefly describe your concern about the student/staff member.

Referred by (Optional):

Providing your name is optional, however, the CARE team can make better decisions with more detailed information. If you are willing to discuss your concern about this student or staff member, please provide your name, contact information, and the best time to reach you.

Referred by First Name:

Referred by Last Name:

Referred by Phone Number:

Referred by Email Address:

Best Times to Contact You, if Needed:

Work Hours (8am - 5pm )

Evening Hours (5pm - 8pm)

Other:

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