Care Team Report
Office of Student Affairs
Name of person(s) completing this form. *If you choose to report anonymously, our follow-up on this report may be limited.
Your email address:
Your phone number:
Date of Concern
Time of Concern
Person(s) of concern
If unknown, put "unknown"
Please identify how the person of concern is associated with HC?
Please supply any other known identifying physical description (if applicable)
Please do not use this to describe the situation.
How can CARE Team best assist you?
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 this individual directly
I am not sure what help is needed
Briefly describe your concerns (facts, dates, observations, etc.)
Please check all that apply
Possible threat made or perceived to self
Possible threat made or perceived to others
Impacted by situational stress or traumatic events that cause disruption or concern
Engaging in risk taking behaviors (substance abuse)
Disruptive or concerning behavior
Extreme changes in mood/demeaner, dress or appearance
Will Not respond to repeated requests for a conference
Excessive absences or tardiness
Poor quiz grades
Poor test grades
Poor homework grades
Poor demonstration of skills
Lack of preparation
Failure to complete assignments
Poor participation in class or lab
Sleeping/drowsiness in class
What steps have you taken (if any) to address your concern?
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