Caltech CARE Team Referral

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CARE Team Referral

This form should be used for non-urgent concerns. If you are concerned about someone with suicidal thoughts or behaviors, threats to the community, or other situations requiring emergency response, please call Campus Security at 626-395-5000 or Counseling Services at 626-395-8331 for assistance.

Acknowledgement

Your Name

Please provide your name and contact information below. If you wish to remain anonymous, enter "anonymous" in the name field. Please note - the CARE Team's ability to follow-up on your concern may be limited if we are unable to contact you for additional information. Typically, a CARE Team member will contact the referring party to gather additional information and follow-up on the situation. A Team member can also discuss any concerns you may have about privacy.

Report Type(s)

What is your affiliation to Caltech?

Email Address

Phone Number

Individual of Concern Type:

Name(s) of Individual(s) of Concern

If available, please provide contact information for the individual(s) of concern.

Description of Concern

Date and Time of Incident (if applicable)

Does the individual of concern know you are submitting a CARE Team referral?

When possible, it is helpful to share your concerns with the individual and let them know you are submitting a referral to help connect them with supportive resources.

Can the CARE Team inform the individual of your referral?

It can be helpful to let the individual of concern know that the CARE Team received a referral on their behalf. This is always done sensitively and framed in terms of community members looking out for one another.

Supporting Documents / Attachments

CARE Report: I am attaching documents to my referral.

Please check this box if you are attaching documents

Attach documents/Upload