CART Referral Form

Repeated absences from class, section, or lab Missed assignments, exams, or appointments Deterioration in quality or quantity of work A noticeable change in academic performance Other (please specify in the narrative below)

Direct statements indicating distress, family problems, or loss Angry or hostile outbursts, yelling, or aggressive comments More withdrawn or more animated than usual Expressions of hopelessness or worthlessness: crying or tearfulness Expressions of severe anxiety or irritability Other (please specify in the narrative below)

Showing a marked change in appearance Statements about change in health, appetite or sleep Noticeable cuts, bruises, or burns Disorganized speech, rapid or slurred speech, confusion Other (please specify in the narrative below)

Food Insecurities Housing Insecurities Feeling of not belonging and/or lack of support in the campus environment Other (please specify in the narrative below)

Death of Family Member Death of Fellow Student Death of Non-Student/Other Misuse of Drugs Misuse of Alcohol Relationship concern Roommate concern Student Impacted by an Event Unable to Locate Student Witness to an Incident Other (please specify in the narrative below)

Concern of self harm Concern of harm to others Other (please specify in narrative below)

Police and/or Campus Safety were called to the incident The student was transported to jail or other location The student was transported to the hospital Immediate Counseling Services response initiated Other (please specify in the narrative below)