Make a Referral - Antioch College

First CARE Referral Form

Use this form if you have a concern about a student which you would like to bring to the attention of the CARE Team. This form is NOT monitored 24/7. If you are sharing a situation involving an imminent threat of harm to self or others, please contact Public Safety at 937-776-0660 or call 911.

Reporter's Information

While not required, we ask that you please share your name and email address. This will allow us to contact you if we have any follow up questions or need additional details. Your name will not be disclosed to anyone who does not need to know.

Name

First Last

Relationship to student of concern

Phone

Email

Date of incident of concern*

Is this an ongoing or one-time event?*

Ongoing event
One-time event

Student of Concern

Student of concern's name*

First Last

Student of concern's phone number

Student of concern's email

Add another person of concern

Yes
No

Student of concern's name*

First Last

Student of concern's phone number

Student of concern's email

Questions

Please be as specific as you can and provide any relevant details that could help us help this student.

Academic Concerns (check all that apply):

Deterioration of work
Excessive absences from class
Inappropriate classroom behavior
Disturbing writing
General academic concerns

Personal Concerns (check all that apply):

Death of a family member or loved one
Financial issues/Basic Needs Assistance needed
Suicidal ideation/thoughts (if imminent please contact Public Safety/911)
Suicide attempt (if imminent please Public Safety/911)
Mental health concerns
Considering leave of absence

Physical Concerns (check all that apply):

Substance use concerns (suspected)
A dramatic change in energy level
Medical issues/hospitalization
Concerning changes in appearance or hygiene
Threatening behavior (if imminent please contact Public Safety/911)
Injury/illness
Unusual behavior
Concussion

Please describe your concern.*

Have you discussed this with the student?*

Yes
No

Please relate what you have discussed with the student to the extent you are comfortable.

While we do our best to keep your information confidential, at times it may be necessary to identify the reporting party. If necessary, may we share your name with the student?*

Yes
No
Not unless absolutely necessary

Do you know if anyone else who has a positive working relationship with the student? If so, who?

How would you like us to follow up with you? Keep in mind, if you did not share your name or email above, we are not able to follow up.*

Phone
Email
Follow up not necessary

Submitter Support

If you are a staff or faculty member and you need support for what you experience, please reach out to HR (hr@antiochcollege.edu) for information about the Employee Assistance Program.

Would you like to speak with Counseling Services regarding the student you are referring? If so, please make sure you shared a good phone number or email above.

Yes
No

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 200MB maximum total size. Attachments require time to upload, so please be patient after submitting this form.

File

Drop files here or

Max. file size: 200 MB.

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