Mott Care Team Report of Concern - Mott Care Team

We Care…Reach Out

Today's Date:

Submitter Information

First Name:

Last Name:

Phone:

Email:

Nature of this report:

Signs or statements of emotional challenges of depression (poor concentration, fatigue, irritability, etc.) anxiety (nervousness, restlessness, panic, feeling of dread, etc.), loss of a loved one (grief, numbness, bitterness, detachment, etc.), extreme weight loss or weight gain, and/or post traumatic stress (Avoidance, dissociation, or overwhelming emotions)

Signs or statements of hopelessness, suicidal ideation, or signs of physical/emotional self-harm

Extreme or erratic changes in behaviors including disengagement or isolation for others, poor attendance or participation, recent loss of interest or unresponsiveness to peer combined with observed distressing behavior

Substance abuse, including alcohol or other drugs

Extreme paranoia, delusions thoughts, hallucinations, confused, disorganized or bizarre thoughts, and/or disruptive behaviors

Other concerning behavior not listed above – please provide detail in the incident details section below

Before submitting a Care Team Report, review the MCC Code of Conduct to establish whether it is a Care Team referral or Code of Conduct violation.

Any attendance issues should be reported in the "My Compass App".

Student of Concern

First:

Last:

Student ID (if known):

Age:

Incident Details

Date of Incident:

Format as mm/dd/yyyy or use calendar widget

Time of Incident:

Place of Incident:

Please provide a detailed description of the incident/concern using specific, concise, objective language (Who, what, where, when, and how).

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