CARE Referral

Date:
Your name:
Role at NSCC:
Email:
Campus:
Preferred contact: (phone or email):
This is only so we can get in touch with you. Your identity will not be shared with the student without your knowledge.

Is the situation urgent?

Yes
Please contact mobile crisis and NSCC Security if the student is planning to harm themselves or others.

Student name:
Student A# (if known):
Student contact phone (if known):

Please select the nature of the concern (choose the most relevant category)

Suicidal Ideation/ Suicide Attempt
Violence Against Others
Self-Injurious Behavior
Sexual Abuse
Domestic abuse
Health/ mental health concern
Financial issue
Homelessness
Other concerning behavior

Please provide a detailed description of the incident/situation using specific, concise, objective language.

Has the incident already been addressed?

Yes, I am filing a report for documentation purposes only
Yes, I shared support resources with the student
No, I am requesting that the Care Team review the situation and follow up.

How can the Care team best help you?

I would like a list of resources that address mental health concerns. For urgent concerns, please call 615-244-7444.
I would like a conversation with a Care Team member about a student.
I would like to meet with a student and a Care Team member together.
Other (please specify)

CARE Team Referral Form

Is the situation urgent?

Please select the nature of the concern (choose the most relevant category)

Please provide a detailed description of the incident/situation using specific, concise, objective language.

Has the incident already been addressed?

How can the Care team best help you?