Behavioral Intervention Team (BIT) Referral Form
The BIT serves as the centralized coordinated body for discussion, intervention and assessment regarding students exhibiting worrisome or concerning behavior, which might pose a threat to self, students and/or others in the University community. All efforts will be made by the BIT, except for legal obligations, to keep information confidential.
Please fill out as completely as possible. Call University Police at 765-285-1111 or 911 for all emergencies.

Items with an * indicate a required field.
Your Contact Information
First Name *
Last Name *
Email *
Your Status at the University *
Phone
 
Referred Person's Information
Full Name of Referred Person *
Referred Person's Email Address
Referred Person's Gender *
Is Referred Person a Student? *  Yes
  No
 
Specific Concerns for Referral
Date of Incident *
(mm/dd/yy)
Location of Incident *
How Did You Become Aware of this Concern? *
Full Name and Contact Number of Outside Source
Concern(s) or Reason(s) for Referral? Check as many as Appropriate *  Alcohol resulting in harm to self/others/both
  Classroom
  Cyber abuse/stalking
  Office disruption that included unusual/bizarrre/threatening behavior
  Person has had a drastic change in behavior/appearance
  Physical assault/domestic abuse
  Self-harm/Suicidal/Hospitalization
Please describe what occurred and any action you took *
Please provide specifics on the incident and be as detailed as possible.