SCT REFERRAL FORM

Student Care TeamSCT REFERRAL FORM

Please note that your contact information is requested only so that a member of the Student Care Team may contact you for further information.

Date of Referral Date of Referral / MM / DD YYYY
When did you first become concerned?
If specific incident(s), please include date(s) of occurrence.
REFERRAL SOURCE
Your Name Your Name First Last
Your Role
Department
Your Phone Number Your Phone Number - ### - ### ####
Alternate Phone Number Alternate Phone Number - ### - ### ####
Your Preferred Email

You will receive an automated communication at your PREFERRED EMAIL once the report is submitted.
The content of this report and attachments may contain information that is protected under the Family Educational Rights and Privacy Act (FERPA). The Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records.

We ask all communication be managed through official Hunter email.
INCIDENT INFORMATION
NAME of STUDENT about whom you are concerned.
If name unknown, provide physical description below. NAME of STUDENT about whom you are concerned.
If name unknown, provide physical description below. First Last
Please indicate student's EMPL ID if known (8 digit number linked to CUNYFirst; Faculty: EMPL ID can be found on your class roster )
Course Name/Section
(if applicable)
Please provide a detailed description of the incident or concern using specific, concise, objective language. Please also include relevant dates, locations, and/or timeframes.
How did you hear about SCT?
How did you hear about us?

How did you hear about us? Department Website Email Word of mouth I've submitted a BRT report before Unsure/ Forgot source SCT Presentation Other
If other, please specify:

SCT REFERRAL FORM

Student Care TeamSCT REFERRAL FORM

REFERRAL SOURCE

INCIDENT INFORMATION

How did you hear about SCT?