Behavioral Intervention Team
Referral Form

If you observe the behavior of a student, faculty or staff member that causes concern, please complete and submit this Behavioral Intervention Referral Form. Any information that you submit will be handled confidentially with the purpose of assisting the student, faculty or staff member you have named. Please complete each section of the form for accuracy of information and follow-up contact in case any additional information should be needed.

IN CASE OF AN IMMEDIATE EMERGENCY, CONTACT CAMPUS POLICE AT 662.862.8300 OR 662.620.5300.

*Required  INDIVIDUAL BEING REPORTED *First Name: *Last Name:                 Middle Initial:     YOUR CONTACT INFORMATION FOR FOLLOW-UP, IF NEEDED *Your First Name: *Your Last Name:                 Your Middle Initial: *Your Address: *Your City:     *Your State:     *Your Zip: *Your Contact Number:    ex.  662-555-5555 *Your Email:     INCIDENT(S) *Date of Incident:          *Time of Incident: *Location of Incident     *REASON FOR CONCERN (CHECK ALL WHICH APPLY) Self-Injurious Concern Aggressive Interaction Disruptive Behavior (includes online behaviors) Alcohol/Substance Abuse Odd/Eccentric Behavior Hopeless/Depressed Demeanor Change in Behavior Personal Issues Other Concerns:   *Describe your concerns (specific details which alarmed you).   If appropriate, list others who where involved.   Other people who may have observed the incident.   *Have you reported this incident elsewhere?   Yes   No     Additional information that would be relevant or that you would like to provide.