Behavioral Intervention Team Referral Form Behavioral Intervention Team Referral Form Full Name of Person of Concern * Gender ID# Person of Concern College Status Current Student Former Student Faculty Staff Department Other Reporting Person's Name * Reporting Person's Contact Information * Reporting Person's Category Instructor Staff Student PD/Security Counselor Friend Outside Source How did you become aware of this concern? Firsthand Observation Reported to You by Someone 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 Physical or Emotional Symptoms that you observed in the individual Feeling Sad/Depressed Strange/Bizarre Statements Mood Swings Expressed Thoughts of Hurting Others Hyper Energy Expressed Angry or Hostile Actions/Feelings Sleepiness Crying Spells Expressed Seeing or Hearing Voices Loss of Appetite Expressed Thoughts of Hurting Themselves Low Energy Overly Anxious or Afraid Other 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 Phone In Person Email Letter Web If you are human, leave this field blank. Submit Δ
March 27 @ 8:00 am - July 3 @ 11:30 pm Secondary Career & Technical Education Center Application Period
