Intervention Referral

DateTime

To report emergency situations that occur on or off Rockford University Campus, call 911.

The mission of the Behavioral Intervention Team (BIT) is to assist in protecting the health, safety, and welfare of students and other members of the Rockford University (RU) community. The Team also provides a systematic response to students whose behavior may be unproductive, disruptive or dangerous to themselves or other members of the RU community.

*RU Faculty with classroom issues or academic concerns should first utilize the academic alert system. This information will be reviewed and submitted to the Student Intervention Team.

This form is for referring any current Rockford University student who may be of concern. This form is confidential and goes directly to Damian Evans, Associate VP for Student Life/Diversity Officer and Scott Mitchell, Assistant Dean and Director of Residence Life.

Please answer the following questions as completely as possible in regards to the student of concern.

Student of Concern *

First Name

Student of Concern *

Last Name

Student of Concern Phone Number

Please enter a valid phone number.

Student of Concern Email

example@example.com

Student of Concern is a*

Commuter StudentResidential StudentUnknown

Description of Incident or Reason for Concern:*

What have you already tried to address this situation?

I have informed the individual of this referral:*

YesNo

Please complete the following information about yourself or skip this section if you would like to remain anonymous. The Behavioral Intervention Team does not disclose the name of the person making the referral.

Name

First NameLast Name

Phone Number

Email

example@example.com