Behavior Intervention Form

Behavior Intervention Referral

Your Information
Name*
First Last
Date of Report*
MM slash DD slash YYYY
Office Phone Number
Other Phone Number
Your Email
Student of Concern
Student ID#
Student Name
First Middle Initial Last
Student Phone Number (optional)
Student Email (optional)
If student's name is unknown, provide a brief description of the student:
Incident Information
Date of Incident
MM slash DD slash YYYY
Time of Incident
: Hours
Minutes
AM/PM
Location of Incident
Witness or others involved
Reason for Concern (check all that apply)
- Self-Injurious Concern
- Aggressive Interaction
- Disruptive Behavior (includes online behaviors)
- Alcohol/Substance Abuse
- Odd/Eccentric Behavior
- Hopeless/Depressed Demeanor
- Change in Behavior
- Personal Concerns
- Other Concerns
Description of Observed Behaviors (use specific, concise, objective language)
Your Digital Signature*
First Last
Comments
This field is for validation purposes and should be left unchanged.

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West Liberty University, established in 1837, was the first institution of higher education in West Virginia. Today, we are a dynamic, inclusive, student-centered community that cultivates scholarly exploration, experiential learning, creative expression, and global citizenship.

WLU is a public university committed to providing students with a comprehensive education from undergraduate to advanced degrees while serving as the region’s leading advocate for the arts, education, research, and economic opportunity.

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West Liberty, WV 26074
Phone: 304.336.5000
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Behavior Intervention Form

Behavior Intervention Referral

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Incident Information

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