Referral Form

Counseling Center

Referral Form

Your name:

Name of Student you are referring:

Any information you believe it is important for us to know (please include any information about suicidal or homicidal comments the student has made):

Have you told the student that you would like for us to follow up with you after his/her meeting? (circle one)

YES NO

If so, what information do you want:

___ If the student attended the first appointment

___ Follow up regarding a student in crisis

If you answered yes, we will attempt to get a release of information from the student. We cannot guarantee that we will be able to release information as we are bound by federal and state laws and ethics that require confidentiality except in certain situations. However, if the student agrees to a release of information, we will be able to communicate that information.

How to use this form:

If the student has a scheduled appointment, you may mail this form to UC 113.

If the student is coming during our crisis hour (3-4 pm any day), you may fax the form or bring it with you if you are walking the student over. Sometimes we are unable to consult much in the moment (depending on what is happening with the student, so this form will simplify communication).

If the student is in crisis and cannot wait until 3 pm, we will have them wait in our office until a counselor becomes available to assess the student/situation.

Referral Form

113 University Center

Phone: 256-824-6203

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