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Care Team Referral


IF YOU OR SOMEONE ELSE IS IN IMMEDIATE DANGER, Please Call 911 or Campus Public Safety at (802) 865-6465


Please note that referrals are reviewed during normal business hours and may not be immediately addressed.

BEFORE YOU BEGIN: If this is an emergency that requires immediate attention, please contact Campus Public Safety at (802) 865-6465 or 911 prior to filling out this referral form. Referrals are reviewed by a variety of campus partners Monday through Friday 8:30am to 4:30pm. This form is NOT designed as an emergency response notification process.

Faculty, staff, students, and others may refer a student who may be struggling with academic, personal, or emotional difficulties or who may be exhibiting concerning behavior. Individuals may also complete this form on their own behalf.

Students referred will be contacted and offered resources by the Care Team. Your concern will be routed to the appropriate office depending on the nature of the concern as described below.

Need to report a Title IX or Sexual Misconduct violation? Please submit that report here

Need to report a Bias Related Incident? Please submit that report here

Your Information

Please provide as much of your information as possible. Providing incomplete information may hinder the College's ability to respond and provide support.

 
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Student Information

Please list the individuals involved (EXCLUDING yourself), including as many of the listed fields as you can provide. For non-affiliate persons, please list a Drivers License number in the block labeled SID if available. If you have listed your information as the person submitting the report, you DO NOT need to include duplicate information. Note: "Respondent" refers to the individual about whom you have concerns. If Champlain College is the student of concern, please use Datatel number 0000000.

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Information About the Concern

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Personal, emotional, or behavioral concerns for this student. Check any that apply.(Required)
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Academic concerns for this student. Check any that apply.
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Have you reached out via-email or spoken with this student about your concern?(Required)
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Duration of Behavior?
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Optional Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission