CARE Referral Form

Background Information

DIRECTIONS: When submitting this report, please include as many details as possible including name, title, and contact information. Please note that submitting the report anonymously may limit the institution’s ability to fully address your concern.

Enable additional features by logging in.

Your full name:

Learn more

Or, you may write Anonymous

Your position/title:

Learn more

(Staff, Faculty, RA, OL, Student/Peer, SGA, etc.)

Your phone number:

Your email address:

Email address must be of a valid format.

Date of Concern(Required):

This field is required.

Time of Concern:

Location of incident(Required):

This field is required.

Specific location:

Learn more

For example: room/office number, wing of hallway, etc.

Involved Parties

DIRECTIONS: Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please indicate them as such.

Student Name

ID Number

DOB (YYYY-MM-DD)

Housing

Information regarding concern for the student(s)

DIRECTIONS: Please provide a detailed description of the incident/concern using specific, concise, and objective language (Who, what, where, when, why, and how).(Required) This field is required.

Please review and acknowledge the following that the above report is not an emergency:(Required)

I acknowledge that this form is NOT for emergency reporting. If the nature of the above information expresses any emergency concerns, including but not limited to, if you or another person is in immediate danger, or a person may harm themself or someone else (made comments related to self harm or suicide), or if a person is injured, unconscious, or incapacitated, that would necessitate an immediate call to Public Safety at 203-582-6200 or 911.

You must make at least one selection.

Supporting Documentation

DIRECTIONS: Please upload any information that supports this report such as pictures, screenshots, reports, emails, etc. 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 regarding concern for the student(s)

Supporting Documentation

Submission