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Behavioral Intervention Team Referral Form




If this is an immediate emergency, please call 911. Referrals made to the Behavioral Intervention Team are reviewed Monday through Friday 8:00 am- 5:00 pm. If you are in need of an immediate response you should call 911.

The Behavioral Intervention Team's (BIT) mission is to identify, assess, and respond to serious or potentially serious concerns or incidents related to student mental health, physical health or conduct which, if disregarded, could threaten the health and safety of the student or the campus community.

By filling out this referral form, you will be alerting the BIT that a student was recently or is still in a crisis. This will permit a supportive response to ensure the student receives necessary assessment and help. Please provide whatever information you can and submit this form. A case manager will reach out to you upon receiving the referral. 

While the BIT will make every effort to provide resources to the student of concern, please know that student participation in the BIT process is, in most cases, not mandatory. Exceptions include serious threat to self and/or others. 

You may report anonymously or request that your identity remain confidential. Nothing herein shall be interpreted to modify any legal requirements applicable to licensed health care professionals’ disclosures of health care information protected by health and medical confidentiality laws.



CONFIDENTIAL MATERIAL

Reporting Party Information

 
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Involved Parties/Student of Concern

Involved party 1

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).

I understand that the BIT only reviews cases Monday-Friday, 8:00am-5:00pm.(Required)
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If a member of the BIT contacts the student, may we share your name and/or details of your concerns? Please note: it is very helpful for the BIT to have the ability to refer directly to the incident. Otherwise, while the BIT will make every effort to protect your identity, complete anonymity can not be assured.(Required)
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Please check all that apply for the type of incident you are reporting:(Required)
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Did the student express an intent to harm self or others?(Required)
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Did the student express a plan?
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Was the threat verbal or written?
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Does the student have the means to carry out the threat?
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Did the student take harmful action?
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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.

Submission