Fillable (800) 678-8426 - Toll Free Name of Person (Eastern Arizona College)

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(800) 678-8426 - Toll Free Name of Person (Eastern Arizona College)

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Date: _________________________
Time: : AM PM
Name: _____________________________________
Name of Person Being Referred
Reason for the Referral:
I
ndicate the seriousness of the situation on a scale from 1 to 10 with 1 being the least concerned and 10 being the most.
1 2 3 4 5 6 7 8 9 10
Follow-Up Request: IMMEDIATE (NOW) Referral Source Name: _________________________________
(Please check one) Name of Person Making Referral
URGENT (SAME DAY) Department: _________________________________
ROUTINE (THIS WEEK) Phone: _________________________________
D
ate Needing to be Seen: _______________
Request an Appointment
Counseling Referral
EAC Counseling Department
(800) 678-8426 - Toll Free
(928) 428-8253
Please describe the situation and your concerns (i.e. behaviors you have observed).
(Please check one)
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(800) 678-8426 - Toll Free Name of Person (Eastern Arizona College)

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Completed 29 January 2021

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