ACT Referral Form

The Assessment and Care Team (ACT) Referral Form allows members of the Juilliard community to report concerns about the wellbeing of students (see “Referral Type” below).

If you wish to report an immediate life-threatening emergency, please call 911 first, and then notify Juilliard Public Safety (212-799-5000, ext. 246) as soon as possible. Information shared in this form will be viewed first by the Dean of Student Development and shared only with relevant parties tasked with formulating a timely response. Every effort will be made to keep the referrer’s information private, but your name and contact information are very helpful in case follow-up by ACT is necessary.

Today's Date*

Date

Referrer's Name

Please provide full name (First and Last). (Optional)

Referrer's Email

Please provide your email address so that we can contact you if we have follow-up questions about this referral. (Optional)

Referrer's Phone Number

Please provide your phone number so that we can contact you if we have follow-up questions about this referral. (Optional)

Please mark the box or boxes below that you believe best address the nature of your concern.

Referral Type*

Academic Concerns: Concerns related to attendance, low grades, poor study skills and other behaviors related to academic performance.Social/Adjustment Concerns: Inclusive of social adjustment issues, not fitting in, homesickness, concerns related to diversity, and roommate or community conflicts.Health Concerns: Inclusive of behaviors such as observed eating disorder behavior, alcohol/drug, prolonged illness, sustained injury, self-harm or cutting behavior, observed depressive behavior, suicidal ideation/attempt, hospitalization, or other like concerns.Personal Concerns: Inclusive of things such as financial concerns, family or general home concerns, death or illness in the family, or legal concerns.Other

Student(s) Involved?*

Please list the name(s), email(s), and/or phone number(s) if possible, of the student(s) about whom you are concerned.

Date and Time of Incident

If your concern relates to a specific incident, what was the approximate date the incident occurred?

Hour MinutesAM/PM Option

Locations of Incident*

On-Campus: Classroom, studio, hallway, lounge, cafe, residence hall, etc.Off-Campus: Anywhere off-campusDigitial/Electronic: Phone call, text, email, social media, etc.Other

Descriptive Information*

Please provide as much information as possible about your concern. Please provide the names of any other persons who may be directly affected by the concern, or may be willing to share additional information.

May we share your name with student(s) about whom you are concerned?*

YesNo