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Confidential Counseling Referral Form
Confidential Counseling Referral Form
Referral Process
Complete Student of Concern Referral Form below.
Referring faculty or staff will be notified when referral form has been received.
In order to maintain confidentiality, the Student Wellness Center may need to limit or keep private information discussed after the referral is processed.
"
*
" indicates required fields
Student Name & Anumber
*
First
Last
Anumber
Student Contact Number (Cell)
Student Contact Number (Other)
Person Completing Referral
First
Last
Relationship to Student
Referred Anywhere else
Yes
No
If Yes, where?
Please describe where else the student has been referred.
Reason for Referral.
Academic Difficulty
Hyperactive, hard to sit still
Anxiety Attack
Inappropriate language
Concerns about student’s writing
Limited resources, clothing, food, hygiene
Cuts or burns, bruising
Poor hygiene
Depressed affect, sad, crying
Poor social skills
Dietary concerns
Relationship problems
Difficulty focusing
Social isolation
Emotional outbursts
Student wants help with alcohol/substance use
Frequent absences
Other
Check all that apply.
Reason for Referral
Please describe.
Have you discussed these concerns with the student?
Yes
No
Please Explain why you have not discussed this with the student.
Briefly describe concern(s) that led to this referral.
Only report the facts, this helps avoiding making judgments and/or opinion statements.