Madison Cares Referral Form

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)

*Your Full Name:

Email:

Phone:

Your Affiliation:

Specify Other:

I'm submitting a referral about...

Information About the Person of Concern

*First Name:

Last Name:

Gender:

Self-Identified Gender:

Role at JMU:

Specify Other:

Academic Level:

Student ID#:

Email:

Phone:

Residence/Address:

Information About Concern/Incident

*Date of Incident/Concern:

*Time:

*Is immediate action required? (Click "Yes" if the student is in danger of hurting themselves or others, if they have current thoughts of suicide or self-harm, or if there is a risk of bodily harm or physical injury) Yes No

*Has Emergency Services been called regarding this concern? Yes No

*Location of Incident:

Specify exact location:

*Nature Of Concern:

Please describe your concern about this student:

*Frequency of concern: One time Ongoing Unsure

Frequency Details:

Have you spoken with the person about your concern?

Is the person aware that you are contacting the Madison Cares team?

Please identify any other parties involved in this situation (names, how they are involved):

Please identify any other parties you have shared this concern with:

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.

Dean of Students

Student Success Center
MSC 3534
738 S. Mason St.
Room 3010
Harrisonburg, Virginia 22807

deanofstudents@jmu.edu
540/568-6468

Madison Cares
madisoncares@jmu.edu