University Counseling Referral Form
Complete this form to refer a student for university counseling services. Please provide as much detail as possible to ensure appropriate support.
Student Information
Please provide details about the student being referred.
Student Full Name
*
First Name
Last Name
Student Email Address
*
example@example.com
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student ID Number
Referrer Information
Details about the person making the referral.
Referrer Full Name
*
First Name
Last Name
Referrer Role/Relationship to Student
*
Please Select
Faculty/Instructor
Academic Advisor
Residence Life Staff
Peer Mentor
Self-Referral
Other
Referrer Email Address
*
example@example.com
Reason for Referral
*
Academic Difficulties
Personal/Emotional Concerns
Family Issues
Behavioral Concerns
Crisis/Urgent Situation
Other
Please provide additional information, observations, or concerns relevant to this referral.
Have any previous interventions or support services been provided to the student? If yes, please describe.
Level of Urgency
*
Routine (within 1-2 weeks)
Soon (within a few days)
Urgent (as soon as possible)
Preferred Method of Contact for Follow-Up
Email
Phone
No follow-up needed
Referrer Signature (please sign to confirm the accuracy of the information provided)
Submit Referral
Submit Referral
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