Faculty/Staff Referral Form
Name: ______________________________________
I am referring you to Counseling Services for personal counseling at no cost to you. A copy of
this referral has been or will be forwarded confidentially to Counseling Services.
My referral is based on the following reasons or behaviors:
Please know that even though I am referring you for counseling services, it is voluntary and you
are not required to go. I do, however, believe it is in your best interest to do so. If you are
interested, please call The Counseling Center at (318) 678-6476 or (318) 771-2565 and schedule
an appointment with Carrie Coley, LPC.
The Counseling Center is located in building F in Suite 250 and staffed by a Licensed
Professional Counselor licensed by the state of Louisiana. All information about you or shared
by you during counseling is privileged and private and will not be shared with anyone outside of
appropriate Counseling Center staff except in cases where state law or professional ethical
considerations dictate. This even includes me unless written consent is given by you to your
counselor.
My hope is that you will take advantage of the counseling services and that it helps you be
successful academically.
Faculty / Staff
