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. Today's Date * Month MonthMar Day Day19 Year Year2019 Referrer's Name * Please provide full name (First and Last) Referrer's Email * Please provide your phone number so that we can contact you if we have follow-up questions about this referral. Referral Type * Please mark the box or boxes below that you believe best address the nature of your concern. Academic Concerns: Concerns related to attendance, low grades, poor study skills and other behaviors related to academic performance. Social/Adjustment Concerns: Inclusive of social adjustment issues, not fitting in, homesickness, concerns related to diversity, and roommate or community conflicts. Health Concerns: Inclusive of behaviors such as observed eating disorder behavior, alcohol/drug, prolonged illness, sustained injury, self-harm or cutting behavior, observed depressive behavior, suicidal ideation/attempt, hospitalization, or other like concerns. Personal Concerns: Inclusive of things such as financial concerns, family or general home concerns, death or illness in the family, or legal concerns. Other Other * Student(s) Involved? * Please list the name(s) and email(s), if possible, of the student(s) about whom you are concerned. Date of Incident Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201720182019 If your concern relates to a specific incident, what was the approximate date the incident occurred? Time of Incident Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Locations of Incident * On-Campus: Classroom, studio, hallway, lounge, cafe, residence hall, etc. Off-Campus: Anywhere off-campus Digitial/Electronic: Phone call, text, email, social media, etc. Other Other * Descriptive Information * 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. May we share your name with student(s) about whom you are concerned? * Yes No Verification * Please enter your full name verifying the information you have provided is accurate to the best of your knowledge.