GWRSD / MSD CARE Team Referral

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This form is to be filled out by GWRSD/ MSD faculty and staff. If this is an immediate concern for safety or a threat to life, crisis protocol should be enacted immediately. This form is not monitored 24/7 and should not be used to notify school district or building administration of an emergency. This referral resource is monitored during normal school hours Monday through Friday except for school breaks.

Email *

Record my email address with my response

Your name

Student Name *

Student Grade *

Other:

How did you learn about the incident *

Personally witnessed/ was involved in incident

Disclosure from the involved parties

Disclosure from counseling department

Disclosure from other concerned parties

Other:

Please list all individuals involved (excluding yourself)

Please check all boxes of concern
*

Academic Concern

Aggressive, excessive anger, or disruptive behavior

Alcohol or other drug use

Basic needs insecurity (e.g., housing, food, clothing, financial)

Changes in appearance, hygiene, or general demeanor

Confused, bizarre, or unusual thoughts or behavior

Difficult life event

Interpersonal/Relationship concerns

Medical or health concern

Missing/Non-response to outreach

Suicidal Ideation/Non-suicidal self-injury

Threats of harm to others

Other:

Required

Describe the reason for your Risk Referral to the CARE team. Provide as much detail as possible and use specific objective language to describe the Risk concern (e.g., who, what, where, when, why, and how). Please include direct quotes where appropriate or summarize specific conversations.

Indicate your perceived level of Risk

Mild risk: Disruptive or concerning behavior. Report is being made out of an abundance of caution and concern rather than any direct behavior and threats.

Moderate risk: More involved or repeated disruption. Possible threat made or present, threat is vague and or indirect. If violence is present it is impulsive and non lethal

Elevated: Increasingly disruptive behavior, student may engage in suicidal thoughts, self-injury and or substance abuse. Threats of violence or ultimatums may be vague but direct.

Critical: The situation has been responded to, however, there has been an imminent risk of harm to self or others.

Clear selection

Is the individual(s) being referred aware of the referral being submitted? Please note that you are not required to notify the individual(s) prior to submitting the report.

Yes

Unsure

Are you aware of any current services or resources that the individual is receiving? If yes, please describe. If no or unsure, please leave blank.

Please email any documentation related to your referral (e.g., screenshots, emails, photos, videos, other written work). to jbaker@sau49nh.gov.

Files sent via email

Clear selection

Submit

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