Emergency Planning & Violence Prevention

ACT Referral Form

If you are concerned about the health, well being, or safety of any individual on campus, you are encouraged to share your concerns or observations by contacting Health & Counseling Services, Student Services, Campus Police, Human Resources or by completing the ACT (Assessment & Care Team) referral form below.

Please, provide as much information as possible. If you do not know the name(s), provide any identifiable information. Referrals are sent to the Assessment & Care Team (ACT) members for initial review.



*Lewis Status (Relationship to Lewis): 
 Other/Unknown (Describe below)


Last Name:

First Name:


Security Password (Please type the word):

Your contact information will be kept confidential.

Helpful Resources


Caring for Our Community ACT 2014.

Video Presentation on Campus Violence.