New Referral - CAST

Part I - Reported By

Your First Name

Your Last Name

Your ID

Your Los Rios ID without the W

Your College Role

Your Division

Your Department

If you are an ARC employee, please provide your title and/or position

Your Position

Your Contact information

Your Phone Number

Your E-mail

Part II - Person of Concern

Person of Concern First Name

Person of Concern Last Name

Person of Concern ID Number

Los Rios ID without the W

College Role for person of concern

Location of incident

Location Details

Please type any additional details about the location of this referral.

Date/Time of incident

Concern: (Check all that Apply)

Academic Concern

(Examples of behaviors observed: disturbing writings, unusual change in academic performance)

Behavioral Concern

(Examples: harassment, disruptive behavior, destructive behavior, homicidal threats, stalking, assault, cyber bullying, carrying weapons)

Mental Health Concern

(Examples of behaviors observed: distressed, inappropriate boundaries, isolation, irritability, self-injurious behavior, alcohol/substance abuse, suicidal ideation/intent, hygiene issues)

Urgency Level

Mild - 1

Moderate - 2

Elevated - 3

Severe - 4

Extreme - 5 (Please also contact college police at 916-558-2221, then press “0”)

If other individuals were also involved with this report (excluding yourself), please list their information in the fields provided:

Additional Person First Name

Additional Person Last Name

ID Number

Los Rios ID without the W

College Role

Part III - Incident Details

CAUTION: Please share only facts and observations. Avoid any terminology or phrases that could be considered diagnostic in nature.
Bad Example: "This student is crazy and is obviously suffering from some mental illness."
Good Example: "After I returned the graded test, the student raised their voice and begin shouting profanity at the other students and myself. He stated that he was very angry and frustrated."

Please provide as much detail as possible in regards to the behavior(s) that prompted your concern. These reports are reviewed by members of The CAST (500 words max)

Details

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ARC Crisis Assessment & Support Team (CAST) Referral