ACT Referral Form

The Assessment and Care Team (ACT) Referral Form allows members of the Juilliard community to report concerns about the wellbeing of students (see “Referral Type” below).

If you wish to report an immediate life-threatening emergency, please call 911 first, and then notify Juilliard Public Safety (212-799-5000, ext. 246) as soon as possible. Information shared in this form will be viewed first by the Dean of Student Development and shared only with relevant parties tasked with formulating a timely response. Every effort will be made to keep the referrer’s information private, but your name and contact information are very helpful in case follow-up by ACT is necessary.
Please provide full name (First and Last). (Optional)
Please provide your email address so that we can contact you if we have follow-up questions about this referral. (Optional)
Please provide your phone number so that we can contact you if we have follow-up questions about this referral. (Optional)
Please mark the box or boxes below that you believe best address the nature of your concern.
Please list the name(s), email(s), and/or phone number(s) if possible, of the student(s) about whom you are concerned.
If your concern relates to a specific incident, what was the approximate date the incident occurred?
:
Please provide as much information as possible about your concern. Please provide the names of any other persons who may be directly affected by the concern, or may be willing to share additional information.