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Care Referral

IF THE STUDENT YOU ARE REFERRING IS A THREAT TO THEMSELVES OR OTHERS, PLEASE DO NOT FILL OUT THE CARE REFERRAL. CALL CAMPUS POLICE IMMEDIATELY AT 609-652-4390 OR DIAL 9-1-1. Please remember, this reporting form is not monitored 24/7 and is not meant to be utilized for life-threatening emergencies.

Thank you for taking the time to complete this Care Referral. To make a strong referral, please include as much detailed information as possible. For example: information about the involved student or students, a description of the concerning behavior or circumstance, and additional context you believe might inform the support provided.

Information from this form, along with the subsequent follow-up steps undertaken by the University is subject to and complies with the Family Educational Rights and Privacy Act (FERPA), which is a federal law protecting the privacy of student education records. In accordance with FERPA, we may not be able to share the outcome of our outreach to the students, but we will always confirm that we have received the alert and will respond appropriately.

Information will be shared on a strictly "need to know" basis in order to refer the student to the correct campus resource or intervene as appropriate. FERPA allows for communication to be shared among "school officials" who have a legitimate educational interest. Under FERPA, there is a clear exception for any risks to health or safety. In addition, state and federal privacy laws prohibit the unauthorized disclosure of personally identifiable health information.

The information shared will not become part of the student's permanent record.

If you have any questions or difficulties with this form please contact Stockton Cares. Contact information: care@stockton.edu or (609) 652-4463. If this is an emergency please contact Campus Police at either 911 or 609-652-4390.

Your Information

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Your full name:

Your phone number:

Your email address:

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Nature of this report(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

Student of Concern

*If you are filling this report out for yourself, please add your information below.

*If you are filling out the report for one or more students with related concerns, please include all names in the same report.

*If you are filling out the report for multiple students with unrelated concerns, please fill out separate reports for each.

For example:
Stacey and Chrissy are roommates and are experiencing a roommate conflict, one report should be submitted.

Alex and Andrea are both not attending your class but they are NOT known to be connected to each other. Alex and Andrea should be included in separate reports.

Name

Z Number

Email address

Referral Details

Supporting Documentation

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