Behavioral Referral Form

Your report allows the Assistant Director of Counseling, Director of Counseling and Associate Vice-Chancellor for Student Affairs (AVCSA), or other appropriate Staff member to follow up with the faculty, staff, or student as well as determine whether others in the community have made similar reports/observations.  Certain cases may be reviewed by the Threat Assessment Team.  

**If a faculty, staff, or student’s behavior appears dangerous/presents significant immediate concerns/poses a threat of harm to self or others, please contact the University Police Department immediately at 336-750-2911.  For consultation on faculty, staff, or student behavior of any nature, please call Tim Pittman at 336.750.3270.

Behaviors which warrant immediate reporting to Campus Police instead of submitting this form:

  • Person displays, uses, or is allegedly is carrying a weapon of any kind
  • Person attempts to use or uses any object as a weapon
  • Person threatens with a clear intention harm to self or others (including written indication of harms or suicide)
  • Assault of any nature including sexual assault

Complete the Behavior Form and it will be forwarded to Tim Pittman, Assistant Director of WSSU University Counseling Center 336.750.3270 or via email at


Examples of reportable behaviors appropriate to report using this form include:

  • Emotional outbursts (yelling or screaming or anger management issues)
  • Verbal or written threats of any nature, without a clear attention
  • Intimidating or harassing others
  • Shift in attitude/behavioral/ emotional well being
  • Material written or spoken in coursework suggesting possibly harming self or others (submit examples of writing)
  • Harassment of others including sexual harassment
  • Disturbing or threatening phone calls or messages (save messages on campus voice mails)
  • Disruptive behavior on campus (including in classrooms)
  • Concerns of physical abuse of student including self-mutilation
  • Any other overt behavior that you may feel uncomfortable with, but is not necessarily an immediate physical threat


Winston-Salem State University

601 S. Martin Luther King Jr. Drive

Winston-Salem, NC 27110

Phone: (336) 750-2000

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