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Behavior Referral

Student Information

Term:

Fall

Spring

Summer

Year:

Student Name:

Student Phone (if known):

Student Email (if known):

What is the best way to contact the student?

Phone

Incident Report

The Behavior Assessment Team seeks your help in identifying Western Texas 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 call 911 for local law enforcement or contact the Campus Security Department at, 325-207-3709.

Academic

Verbal Aggression

Family Issues

Physical Aggression

Alcohol/Drug Abuse

Hopelessness

Weapons Grudge

Student Writings

Disrupting Classroom

Physical Stalking

Eating Issues

Cyber Stalking & Harassment

Adjustment

Inappropriate Interests

Self Injury

Have others shared with you that they are also concerned about this student?

Yes

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

(If you do wish to remain anonymous, the chairperson of the team may still contact you for further information.)

Your Name:

Your Phone:

Your Email:

Date:

I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary actions as stipulate on College Policy.

6200 College Avenue, Snyder, TX 79549 * Campus Operator 325-573-8511 * Toll Free 888-468-6982

Western Texas College

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