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) at your earliest convenience. Information shared in this form will be viewed first by the Associate Dean for 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 crucial in case follow-up by ACT is necessary. When you submit this form, the owner will be able to see your name and email address.
Please provide full name (First and Last)
Please provide your phone number so that we can contact you if we have follow-up questions about this referral.
Please mark the box or boxes below that you believe best address the nature of your concern.
Please list the name(s) and email(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?
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Please provide as much information as possible about your concern. In a concluding paragraph, please provide the names of any other persons who may be directly affected by the concern.
Please enter your full name verifying the information you have provided is accurate to the best of your knowledge.