CARE Team Referral Form

CARE Team Members

Carin Benning
Coordinator of Professional and Technical Pathways Advising
937.778.7808

Velina Bogart
Adjunct Faculty/ARC Advisor
937.778.7854

Rachel Carlisle
Director of Regional Campus Enrollment Management & Student Services
937.778.7895

Dr. Jessica Chambers
CARE Team Chair | Dean of Student Engagement
937.778.7849

Dr. Paul Heintz
Dean of Arts and Sciences
937.778.7921

Bruce Jamison
Director of Public Safety & Security
937.778.7837

Caryn Scott
Associate Professor of Social Services
937.778.7927

		Your Information
*Full Name
Work Phone
		Required format 000-000-0000
Home Phone
		Required format 000-000-0000
Cell Phone
		Required format 000-000-0000
*Email
		Information About Person of Concern
*Full Name
ID Number
		If applicable.
*Severity Level
*Behavior Choose as many as apply.		Agitation Aggression Anger Anxiety Depression Emotional Instability Hyperactivity Impulsive Behavior Isolation Self-Blame Self-Harm Other (If "Other", please explain below.)

*Observation Date(s)
		If multiple observation dates, enter each date followed by a semicolon [ ; ].
*Observation Time(s)
		If multiple observation times, enter each time followed by a semicolon [ ; ].
*Observation Location(s)
		If multiple observation locations, enter each location followed by a semicolon [ ; ].
*Detailed Description

CARE Team Members