Intervention and Referral Request

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Person Providing Information

If this is an emergency, please call the Jefferson State Police Department – (205) 856-6093

Date of First Concern

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Name

First Last

Your relationship to the person of concern

Phone

Email

Name

First Middle Last

Possible Nickname

Jefferson State Email

Student Phone Number

Student A Number

Gender

Approximate Age

Campus

Instructor's First & Last Name

Name of the Class

Class Section Number

Building

Room

Time

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Check all that apply.

Please share more details about student's or faculty/staff member's concerning behavior below.