Counseling Referral Form (Confidential)
Fall 2013
Date: __________________
Student’s Name: ID# ______________
Referral Source:
Administrator Faculty Staff Self Peer
Your Name: ________________________________
Department: ________________________ Contact Number: ________________
Reason for Referral: Personal Counseling Crisis Intervention
(Specify Below) (Specify Below)
Explain Concern (Please be specific - Use reverse, if needed):
Counselor Use Only:
Date Received:
Counselor Name:
Session Outcome:
Follow-Up Scheduled Date:
Referred: Campus Community
FERPA permits school officials to disclose information about students, without their consent,
information that would protect the health and safety of students or other individuals.