Counseling Alert Form
Please call me. A student needs support.
In order to protect the confidentiality of your student, please do not give us any identifying
information about your student either via email or in the mail. We will call you to get the contact
information on your student and then we will make the contact with your student. Please notify the
student that you are referring him or her to Counseling Services. Send this form to the Counseling
office, Wynn Center, room 10-209 or email it to Karen Mosley-Lyon.
Please complete the following information and a counselor will call you:
Instructor’s Name: _________________________________________________________________
Instructor’s current phone number(s): __________________________________________________
Instructor’s current email address: ___________________________________________________
Date: _________________ Course and Section Number: _________________________________
This student is being referred for counseling services because:
☐ This is an Early Alert Student: This student is in a developmental studies or ACA 122 class and
is experiencing personal “life” issues. (If this is a referral for tutoring, please use the Academic
Alert Tutoring form).
☐ This is a student who does not meet any of the above criteria but I believe could benefit from
talking with a counselor.
Notes:
Student Development, and Support 8/16/2018
