ACT Referral Form

If you are concerned about the health, well being, or safety of any individual on campus, you are encouraged to share your conerns or observations by contacting Health & Counseling Services, Student Services, Campus Police or by completing the ACT (Assessment & Care Team) referral form below.

 

 
Please, provide as much information as possible. If you do not know the name(s), provide any identifiable information. Referrals are sent to the Assessment & Care Team (ACT) members for initial review.
   
PERSON/SITUATION INFORMATION:
   
Name(s):
 
*Lewis Status (Relationship to Lewis): 
Faculty
Staff
Other/Unknown (Describe below)
 
Details: 
 
YOUR CONTACT INFORMATION:
   
Last Name:
First Name:
Email:
 
Your contact information will be kept confidential.