Behavioral Intervention Team Incident Report

To make a referral to the Behavior Intervention Team, please complete the form below, which will be directed to the Counseling Center in the Library Building, room 422. You are encouraged to forward all other documentation to the Counseling Center as well. Feel free to call the center at ext. 6370 with any additional comments or questions you may have. Please know that while it is not required that you include your contact information in the report, we do request it in the event that we need to reach out to you for further information.

When completing the Description of Behavior section below, please describe the student behavior in concise, objective language. Please note that if there is an imminent threat to anyone’s safety or if an emergency is in progress, please call our Public Safety Office immediately at ext. 6320.

* Student Full Name (First, Middle, Last):

Your Name:

Your Title:

Your Phone:

* Your Email Address:

* Date of Incident:

* Time of Incident:

* Location of Incident:

Description of Behavior:

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