Referral Form

Please complete the form in its entirety including the Date/Time of the Concern, Nature of Concern, and as much of the Student's Information as possible, then click submit. You will receive a confirmation email from Madison Cares within 24–48 hours.

If this is an EMERGENCY, call Public Safety at 540-568-6913 or 911, then enter a Care Referral for Madison Cares to follow up. If you have questions regarding Madison Cares processes, please call the Dean of Students at 540-568-6468.

Note: All items marked with * are required.

Your Information (Person Referring)
Information About the Person of Concern
Information About Concern/Incident
Yes No
Yes No
One time Ongoing Unsure

Click 'Submit' below to send your request.


Any information you enter concerning a student is protected by FERPA, the Family Education Rights to Privacy Act. Students have a right to view the information that you submit to us if requested.

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