CARES Referral Submission

Use this form to share concerns you may have about a Kentucky Wesleyan College student's academic performance, health, well-being, or behavior. This information will be shared with the CARES team and can be used to link a student with resources to assist them. This is a non-disciplinary process and should not be confused with a KWC Student Conduct Incident Report or Title IX Complaint Submission.

For further information on when to submit a referral, see the CARES team website.

IMPORTANT: This form is for non-emergency referrals only. If any person may be in danger, call 911 immediately. Before using this form, call the Counseling Center (270-852-3183) in reference to any situation involving direct statements or actions suggesting that a student has plans to harm themselves or someone else.

What Happens Next: Referrals are typically reviewed within 1-2 business days of submission. Not every referral results in outreach to the student involved. Direct outreach often depends on the nature of the concerns shared and any collateral or historical information that may be available. If a student is already connected with appropriate resources, direct outreach might not occur. Any outreach to a student is non-confrontational and designed to help the student navigate any additional strategies and resources that may be useful. The CARES team works with a range of campus partners for outreach, when warranted.

Submitter Information

Your Name

First Last

Your role with Wesleyan:

Your Phone Number:

Your Email Address:

Are you okay with the person of concern knowing that you submitted this report?(Required)

Though anonymous reports are permitted, doing so will limit the college’s ability to respond. Our general practice is not to share the source of a referral, even when named.

Yes

Student of Concern Information

Is this referral for an online course?(Required)

Yes

Student of Concern Name(Required)

First Last

Cell Phone of Student of Concern (if known)

Email Address of Student of Concern (if known)

Nature of Concern(Required)

Academic Performance or Attendance Concerns:

Course Name

Please describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible. Please include specific statements that were made and provide any context that may be helpful to better understand the situation. If you are aware of other relevant history or concerns, please share those as well.(Required)

Are you aware of whether this person is already connected with certain resources for support? This could include a range of offices or individuals, including counseling, student success, athletics, student organizations, important mentors, etc. If so, please include that here as context for our staff.

Lastly, are there any additional steps you have taken personally to support this person that you have not already included above? This could include a plan you created with them, a conversation you had with them, or other steps taken.(Required)

Please upload any supporting documentation that will help us address this concern.

Photos, video, email, and other supporting documents can be attached below

Drop files here or

Max. file size: 50 MB.

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