Intervention and Referral Request

IF THIS IS AN EMERGENCY, CALL (205) 856-6093

Behavioral Care Team Intervention And Referral Request

JeffCare Referral Form

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Person Providing Information

If this is an emergency, please call the Jefferson State Police Department – (205) 856-6093
Select below if you would like to anonymously submit this form
Name

The Person of Concern Information

Name

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

Time
:

TYPE OF CONCERNING BEHAVIOR

Check all that apply.