Behavioral Intervention Team Referral Form
"Speak up, speak out for a safer campus!"

 

Please provide your information:

 
Your Last Name:     First Name:   
Phone:
Email Address:  

 


Information about the Student of Concern:
 

Student ID: (If known)
Student Last Name:     First Name:    M.I.:
Student Phone Number: (If known)
Other Identifying Information:
   


Level of Referral Key: (Select ONE)

 

Mild Change in behavior (i.e. anxiety, depression, stress etc.)
Elevated Disruptive behavior, showing signs of distress (emotionally and mentally)
Severe Shared consistent threat including plan that could be carried out
Extreme Threat made and repeated with references to weapons, etc.
 


Reason(s) for Referral (Check all that apply)
 

  Aggression   Depression    Peer Problems
  Agitation   Emotional    Self-blame
  Anger    Hyperactivity    Self-harm
  Anxiety    Impulsiveness    Substance Abuse
  Behavior problems    Isolation    Other: 
 


Behaviors Observed or Incident Information:
 

Date of Observation/Incident:
 

Time of Observation/Incident:

Location of Observation/Incident:

 

   

Please write a brief description of the behaviors you observed or the incident you are reporting.

   
        

 

 Piqua Campus - 1973 Edison Drive, Piqua, Ohio  45356 937-778-8600
Greenville Campus 601 Wagner Avenue, Greenville, Ohio   45331 937-548-5546
1-800-922-3722
www.edisonohio.edu