UMES - Counseling Center Form

Counseling Services
Dr. Ron McLean, Director

Office: (410) 651-6449
Fax: (410) 651-7752

Counseling Services Referral Form
Early Alert

Referrals from faculty and staff, help counselors identify students who may benefit from timely assistance. Some students experience problems in the first three weeks of instruction, which if caught in time, could be resolved. Failure to resolve a problem may result in our losing the student. If you are unable to assist the student in resolving his/her challenge(s), please refer them to Counseling Services by calling extension #6449 with information about a student who may need assistance. Next, complete this form and fax or send to the Student Development Center-Suite 2260. Depending on the problem, we will contact the student directly or call you for more information. Our collaborative efforts will allow us to possibly recognize early warning signs, detect a distressed student; and implement prevention/intervention strategies that could save a student and enhance student success. We thank you for your assistance and we look forward to working with you!

Referral To:

Date:

Student Name:

ID#:

Student Address:

Zip Code:

Classification:

Major:

Phone:

Type of Referral:

If Other:

Referred By:

Title:

Department:

Campus Phone(s):

Reasons For Referral:

Was the student informed of this referral?

Counseling Services Referral FormEarly Alert

Counseling Services Referral Form
Early Alert