Clarion BIT Notification

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Urgency of this report(Required):

This field is required.

Date behavior started.(Required):

This field is required.

Time behavior observed.:

Location of incident(Required):

This field is required.

Specific location:

Person or people you are concerned about

Name

Role of person being referred.

ID Number

Phone number

Email address

Hall/Address

BIT Referral Information

Please describe the behavior of the person or persons you are referring.(Required) This field is required.

Has the person expressed an interest to harm others?(Required) This field is required.

Has the person expressed an interest to harm themselves?(Required) This field is required.

Do they have access to items which could be used to carry out a plan to harm self or others?(Required) This field is required.

Please describe any plan to harm self or others expressed by this person or group. This field is required.

What is your level of concern for the person you are submitting this referral on?(Required)

Low level of concern Moderate level of concern High level of concern

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Person or people you are concerned about

BIT Referral Information

Supporting Documentation

Submission