Intervention and Referral Request IF THIS IS AN EMERGENCY, DO NOT USE THIS FORM. CALL (205) 856-6093 Behavioral Care Team Intervention And Referral Request JeffCare Referral Form Person Providing InformationIf this is an emergency, please call the Jefferson State Police Department – (205) 856-6093Date of First Concern MM slash DD slash YYYY Select below if you would like to anonymously submit this form I would like to remain anonymous. Name First Last Your relationship to the person of concernRelativeClassmateInstructor/StaffNo RelationPhoneEmail The Person of Concern InformationName First Middle Last Possible Nickname Jefferson State Email Student Phone NumberStudent A Number GenderMaleFemaleOtherApproximate Age CampusJeffersonShelbyPell CityClantonDistance LearnerIf the person is in a class with you or you know of a class that they are taking, please include the following:Instructor's First & Last Name Name of the Class Class Section Number Building Room Time : Hours Minutes AM PM AM/PM TYPE OF CONCERNING BEHAVIORCheck all that apply. Academic Concerns Emotional/Mental Health Concerns Suicidal Thoughts Self-Harm Childcare Insecurity Housing Insecurity Physical Health Transportation Insecurity Other: Please specify in the description box below. Please share more details about student's or faculty/staff member's concerning behavior below.CommentsThis field is for validation purposes and should be left unchanged. Δ
