Referral Form


  • Counseling Services
    REFERRAL FORM

    Instructions: Faculty and staff using this form should consider all referrals as confidential. Complete the information requested, if hand delivered place in a sealed envelope and forward to Counseling Services in the Student Development Center, 2ndFloor – Suite 2260. You may also fax referrals by using the fax number provided on the bottom of this form. Please try to complete this referral form with the student’s assistance. Parents will be notified only with the student’s permission, and/or if the student has any suicidal /homicidal ideations, or if someone has caused them any harm.
    Student Last Name: First Name:
    Date of Referral: Classification:
    Student ID#    
    Local/Campus Address:   Sex:
    Telephone #s:   Gender:
    Emergency Contact: Phone Number:
    Relationship:    
    Behaviors reported or observed:
                
    Unusual behaviors (explain):

     
    Reason for referral:  
    Was the student informed?  
    Actions taken prior to referral:  
    Any past history of psychiatric services:  
    Medication (if known):  
    Drugs Alcohol
    Substance Use    
    Medical Concerns:  
    Referred by: Department:
    Telephone #: Email:
    Counseling Services Telephone Numbers: Office: 410-651-6449 / Fax: 410-651-7752