Missouri Valley College -Student of Concern Report

The Behavioral Intervention Team is comprised of key members of the Missouri Valley College community who work to support the well-being of students, faculty, and staff. To provide the best possible care for our community, the team uses these reports to aid in the identification of students in need of guidance and support. This report is not intended to be a disciplinary referral, but rather a way for us to know about issues students are having and providing them with appropriate support.

If you believe the student or community is in immediate danger, please contact the Department of Public Safety at (660) 815-0111 or the Student Affairs On-Call at (660) 815-2748.

Today's Date: Month

Day

Year
Name:
Phone:
Other ways to contact student:
Students Issues of Concern:
Academics Family
Student Life Dating/Relationships
Athletic Participation Drug Abuse/Misuse
Alcohol Abuse/Misuse Adjustment/Transition
Emotional Abuse Physical Abuse
Verbal/ Cyber Harassment Physical Harassment
Emotional Disorder Mental Disease
Change of Appearance
Students Actions of Concern:
Self-harm threats Carries weapons
Self-injury Verbally Aggressive / Harassing
Physically Aggressive Disrupts Classroom

Please comment further on the concerning behavior:
Have other individuals witnessed your concerns about the student? If yes, provide names:
What, if anything, have you done to address this concern:
Do you wish to remain anonymous to the student? No        Yes
Your Name:
Your Phone Number:
Your MoVal E-mail Address: