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Behavior Intervention Team Report

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STUDENT INFORMATION

Term Fall Spring Summer
Year
Student Name
What is the best way to contact the student? Email Phone
Please enter your Email Address or Phone Number (based on previous question)

REPORT

The Dean of Student Affairs seeks your help in identifying Wesley College students who are in need of guidance and support. The purpose of this report is for you to be able to alert us of students whose actions and behaviors are causing concern. This report will not be used to initiate disciplinary action, but rather to get help for the student.

If you believe the student or the community is in immediate danger, please contact the Safety and Security Department at (302) 736-2436.
Behavior Observed
Academic
Family Issues
Alcohol/Drug Misuse
Weapons
Grudges
Alcohol/Drug Danger to Community
Disrupting Classroom
Eating Issues
Adjustment
Self-Injury
Verbal Aggressions
Hopelessness
Student Writings
Physical Stalking
Cyber Stalking/Harrassment
Inappropriate Interests
Physical Aggression
Have others shared with you that they are also concerned about this student? Yes No
Would you be willing to share their names? If, Yes, please list them below.
Please comment on the concerning behavior:
What, if anything, have you done to address this concern?
Do you wish to remain anonymous to the student? Yes No
Your Name
Your Phone
Your Email Address
I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that my misrepresentation of information may result in disciplinary action as stipulated in the Student Code of Conduct.