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 Information

    If this is an emergency, please call the Jefferson State Police Department – (205) 856-6093
  • MM slash DD slash YYYY
  • The Person of Concern Information

  • If the person is in a class with you or you know of a class that they are taking, please include the following:

  • :
  • TYPE OF CONCERNING BEHAVIOR

  • This field is for validation purposes and should be left unchanged.