RU Cares - BIT Referral Form

RU Cares - BIT Referral Form
Thank you for taking the time to share your concerns regarding an individual at Reinhardt University. By sharing your concerns, you are helping to maintain a healthy and safe campus environment at Reinhardt University.

To facilitate this process, this report has been provided to encourage faculty, staff, students, and other community members to report observed behavior that warrants concern for the safety of the community and/or the safety of an individual.

Once your referral is received, a staff member on the Behavioral Intervention Team (BIT) will review the information along with additional information to make the most informed decisions about how best to intervene and support the subject of concern.

A BIT member may contact you for additional information. If you wish to make an anonymous report of concerning or worrisome behavior, the staff member will evaluate the report and determine what follow-up (if any) is necessary to address the concerns. You are strongly encouraged to provide your name and contact information to allow us to call or email if we have additional questions regarding your report.

Please note submissions are monitored Monday through Friday between 8:30 am and 5:00 pm.

If this is an emergency, please call University Public Safety (770-720-5911) or 911.
Background Information - Tell us about you

Please provide your own contact information in case we need to follow up with you for additional information.
Your Full Name

First NameLast Name
Your Position/Title
Your Phone Number
Please enter a valid phone number.
Your Email Address
example@example.com
Urgency of this report*

Informational Report OnlyRoutine Response RequestedUrgent Response Required
Nature of this report*

Potential harm to selfPotential harm to othersOther
Involved Party

Please enter information regarding person of concern.
Name*

First NameLast Name
Student ID Number
Email
example@example.com
Phone Number
Please enter a valid phone number.
If possible, please provide any known social media handles for this individual:
Incident Information

Please provide a description of the concerning behavior and/or incident. Provide as much detail as possible in the narrative regarding who, what, where, when, etc.
Date of Incident*

MonthDayYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Location of Incident*

On CampusOff CampusUnknown
Specific Location of Incident
Description of Incident*
Describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible, including dates for any specific concerns. If the concern involves threats or comments related to self-harm or harm to others, please include exact quotes and how these comments were communicated:*
Based on the description you provided, please check any behaviors below that have led you to be concerned about the individual involved:*

AcademicsAttendance/EngagementBizarre/disjointed thoughtsCommunicating threatsCutting behaviorsDating violenceDepressed/persistent sadness/unexplained cryingDisplay or use of weaponDisruptive classroom behaviorDisturbed eating behaviorsDisturbing written material/class discussionExcessive anxietyExtreme mood swingsFamily stressFinancial stressFood/Housing/Financial InsecuritiesHomicidal ideationInappropriate display of anger/negative emotionsInjury/IllnessIntimidationInterpersonal conflictInvolves alcohol/substance useMental healthObsessively suspicious/paranoidPersonal crisis (death of family member or friend)Physical attackProperty damageSelf-harmSexual misconduct (sexual assault, harassment, intimate partner violence)Significant change in appearance/behaviorsStalking (including cyber stalking)Suicidal ideationSuicide attemptUnresponsive to communications (after multiple contact attempts)
Please indicate your observations regarding the person of concern.*

Suicidal remarks, thoughts, or actionsChange in appearancePhysical signs of distressAttendance concernsEmotional signs of distressUnusual behavior in groups or classOther
Please indicate if any of the following actions actions occurred:*

Police calledArrestReported to Title IX OfficeEMS transportEMS called- transport refusedEMS called- no transport neededVoluntary hospitalization (mental health)Involuntary hospitalization (mental health)None
Have you talked to or corresponded with this individual about your concern?*

YesNo
Supporting Documents - Photos, video, email, and other supporting documents may be attached below.

Cancelof
I understand that referrals from this form will be received during normal business hours (Monday - Friday, 8:30AM - 4:30PM) and are not monitored after hours, on weekends, or during official university holidays. Please contact Reinhardt University Public Safety by dialing 911 if there is immediate risk of harm to self or others prior to submitting this form.*

Yes, I understand
Should be Empty:

RU Cares - BIT Referral Form

Background Information - Tell us about you

Involved Party

Incident Information