CARE Team Referral

Background Information

Please provide as much information as possible.

Enable additional features by logging in.

Your full name:

Your position/title/role:

Learn more

Please provide your title or position at GC. If you are a student, please enter student.

Your phone number:

Learn more

What is the best number to reach you if we have questions?

Your email address:

Email address must be of a valid format.

Nature of this referral(Required):

This field is required.

Learn more

What is the nature of your concern?

This referral is about a:(Required):

This field is required.

Learn more

This is not your role in the University but that of the person you are reporting.

Date of Incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Learn more

Where did the incident occur?

Location (Room#, Street Name):

Learn more

Please provide more information concerning the location, for example the room number.

Involved Parties

Please list the person or persons you are concerned about.
Provide as much information as possible.

Name

GC ID Number (Do not use dashes)

The best phone number to reach this person

Email address

Hall/Address

Information on the Student of Concern

What is the purpose of this referral?(Required)

I am concerned about someone I wanted to make the CARE Team aware of the situation but not necessarily requesting action be taken I am providing an update on someone who has already been referred to the CARE Team I am not sure

This field is required.

How can the CARE Team best help you?(Required)

No assistance needed just an FYI I would like advice on how to help this individual I would like the CARE Team to reach out to the person I am unsure what help is needed

You must make at least one selection.

As the reporter of this concern, what is your affiliation with Georgia College?(Required)

Student Faculty Staff Police Parent/Guardian Other (see below)

You must make at least one selection.

If other, please explain your relationship to the student of concern? This field is required.

Please indicate the relevant category(ies) that pertain to this referral, if applicable. ACADEMIC CONCERNS

Repeated absences from class or lab

Repeated absences from work

Missed assignments, exams, or appointments

A noticeable change in academic performance

Other (please specify in the narrative below)

You must make at least one selection.

PHYSICAL CONCERNS

Showing a marked change in appearance

Statements about change in health, appetite or sleep

Noticeable cuts, bruises, or burns

Disorganized speech, rapid or slurred speech, confusion

Other (please specify in the narrative below)

You must make at least one selection.

BEHAVIORAL AND EMOTIONAL CONCERNS

Direct statements indicating distress, family problems, or loss

Angry or hostile outbursts, yelling, or aggressive comments

More withdrawn or more animated than usual

Expressions of hopelessness or worthlessness: crying or tearfulness

Expressions of severe anxiety or irritability

Other (please specify in the narrative below)

You must make at least one selection.

SOCIAL OR CULTURAL CONCERNS

Food Insecurities

Housing Insecurities

Feeling of not belonging and/or lack of support in the campus environment

Other (please specify in the narrative below)

You must make at least one selection.

OTHER CONCERNS

Death of Family Member

Death of a Student

Death of Non-Student/Other

Misuse of Drugs

Misuse of Alcohol

Person Impacted by an Event

Unable to Locate the Person

Witness to an Incident

Other (please specify in the narrative below)

You must make at least one selection.

SAFETY RISK CONCERNS

Written or verbal statements which mention despair, suicide, or death

Severe hopelessness, feelings of sadness, isolation, and withdrawal

Statements such as “going away for a long time” made by the student

Other (please specify in the narrative below)

You must make at least one selection.

Please describe the incident that occurred or the concern you have?(Required) This field is required.

Duration of Behavior(Required)

Single Incident On-going

You must make at least one selection.

If ongoing, when was the behavior first observed? This field is required.

Have you reached out to the person of concern? Although you are not required to, this information is helpful for us to know.

Yes No Upcoming appointment or follow-up Self-Reporting

You must make at least one selection.

The student/faculty/staff disclosed that they:

Are seeing someone in Counseling Services at Georgia College Are seeing a personal therapist or counselor Have been hospitalized in the past for mental health issues Have been or are currently in treatment for alcohol or drug addiction

You must make at least one selection.

Select any of the following Emergency Services involved (if applicable):

GC Public Safety

Milledgeville Police Department

Baldwin County Sheriff's Office

Baldwin County Fire Department

Georgia State Patrol

EMS transport

EMS called - refused transport

EMS called - no transport needed

You must make at least one selection.

Are you aware of any of the following circumstances?

The person was taken to Baldwin County jail The person was jailed elsewhere (please put in the narrative) The person was taken to River Edge Behavioral Health Center - Baldwin The person was taken to Atrium Health Navicent Baldwin in Milledgeville The person was taken to Atrium Health Navicent Macon (formerly The Medical Center) The person was taken to Piedmont Macon Medical Center (formerly Coliseum Medical Centers)

You must make at least one selection.

Do you wish to remain anonymous if/when the person is contacted? **If it is your preference to remain anonymous, the CARE Team member will make every effort to maintain anonymity. However, please know anonymity can never be guaranteed. Reports on students submitted through The CARE Report are student records protected under the FERPA privacy regulations. This includes students having access to their records. The CARE Team or other University Officials may need to follow up to gather additional information to help us most effectively support the reported individual.(Required) This field is required.

Are you aware of other information that would be helpful for us to know about this person? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 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

Information on the Student of Concern

Supporting Documentation

Submission