Behavioral Intervention Team Referral Form

Full Name of Person of Concern*

Gender

ID Number

Person of Concern College Status

Department

Other

Reporting Person's Name*

Reporting Person's Contact Information*

Reporting Person's Category

How did you become aware of this concern?

Concerns or Reasons for Referral?*

Classroom disruption that included unusual/bizarre behavior

Person self-disclosed information

Person has acted in a threatening manner

Non-classroom disruption that included unusual/bizarre behavior

Drastic change in behavior or personal appearance

Other concerns

Select all that apply.

Other Physical or Emotional Symptoms

Specifics on Incident(s)Please be as detailed as possible.

Any other helpful information.Please be as detailed as possible.

Report Received by BIT Member

Method of Intake