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 Intervention and Referral Request Person Providing InformationName First Last Your relationship to the person of concernRelativeClassmateInstructor/StaffNo RelationPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email The Person of Concern InformationName First Last Possible Nickname GenderMaleFemaleOtherApproximate Age If the person is in a class with you or you know of a class that they are taking, please include the following:CampusJeffersonShelbyPell CityClantonBuilding Room Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Immediate NeedsCheck all that apply Assistance with housing Assistance with clothing Assistance with food TYPE OF CONCERNING BEHAVIORCheck all that apply. Significant change in personal hygiene or appearance Significant change in energy level Change in mood, personality or behavior Withdrawn –Complaints of fatigue Inability to focus or concentrate Unusual or erratic performance, speech behaviors Significant change in weight Threat of self-harm Visible Injuries - cuts, burns, etc. Farewell statements alluding to not ever seeing people again Tearfulness or repeated episodes of crying Giving away prized possessions Feeling of hopelessness Expressions of worthlessness Difficulty controlling emotions Academic or workplace performance concerns Excessive absenteeism / missing scheduled classes or appointments Tardiness to class or appointments Comments related to sleeping issues / nightmares Direct threats toward an individual or individuals Displays unprovoked anger, aggression or hostility Unusual writing or drawings Demanding Inappropriate outburst or reactions Intimidating Preoccupation with violence Expressions of worry or anxiety Feeling suspicious of others Suspected drug or alcohol abuse Odor of alcoholic beverage Cultural factors Problems making friends Stares inappropriately at others Invades personal space of others Makes unwanted physical contact Abusive to animals Preoccupied with fire Please indicate selections from the relevant category/categories. Circumstances associated with the person of concern that have been reported or known to you personally.Check all that apply Is not engaged in seeking treatment for diagnosed health condition History of alcohol/drug abuse Has suffered personal or financial loss Destruction of property Fire setting or arson Suffered childhood abuse or neglect Suffered sexual assault or abuse Committed sexual assault or abuse Victim- history of relationship/domestic violence Offender- history of relationship/domestic violence Fantasy of harming people History of planning a violent event Fascination with weapons Owns or has access to weapons Has made homicidal statements History of violent, reckless or antisocial behavior History of suicide attempt Other (Please provide details below) None of these apply Other - Please type your details below.Indicators & Behaviors of Suspected TerroristsCheck all that apply Breach/Attempted Intrusion - Unauthorized personnel; attempting to enter or actually entering secured area. Misrepresentation - Presenting False information or misusing insignia, documents, and documents, and/or identification misrepresent one's affiliation as a means of concealing possible illegal activity. Theft/Loss/Diversion - Steeling or diverting something associated with a facility/infrastructure for the purpose of committing an act of terrorism. Cyberattack – Compromising or attempted to compromise or disrupt an organization’s information technology infrastructure. Expressed or Implied Threat – Communicating a spoken or written threat to commit a crime that will result in death or bodily injury to another person or persons or to damage or compromise a facility. Aviation Activity – Learning to operate or operating an aircraft in a manner that poses a threat of harm to people or property. Eliciting Information – Questioning individuals at a level beyond mere curiosity about events, facilities, and related security procedures. Testing or Probing of Security – Deliberate interactions with people or installations for the purpose of revealing security capabilities or weaknesses. Recruiting/ Financing – Providing direct financial support and or assistance to a terrorist group. Photography- Taking pictures of facilities or buildings in an unusual manner that would be arouse suspicion in a reasonable person. Observation /Surveillance – Demonstrating unusual prolonged interest in a facility beyond casual or professional interest. Material Acquisition / Storage – Acquiring and or storing unusual quantities of materials for use in unlawful activities. Acquisition of Expertise – Attempts to obtain or conduct training in security concepts, military weapons or tactics for other than lawful purposes. Weapon Collection / Discovery- Collection of unusual amounts of weapons, ammunition, explosives, or toxic chemicals for other than lawful purposes. NameThis field is for validation purposes and should be left unchanged. Δ
