Student Health Services
Referral Form for Student of Concern
Phone: 619-388-2774 Fax: 619-388-2853 Email:
Office: I4-209
Complete Student of Concern Referral Form and email or fax form to Suzanne Khambata at Student
Faculty and staff will be notified when referral form has been received.
In order to maintain confidentiality, Student Health Services may need to limit or keep private
information discussed after the referral is processed.
Student Name: ________________________________ ID # _____________________
Date of Referral _________________________________________________________
Student contact numbers (cell) ___________________ (other) ____________________
Person completing referral _______________ Relationship to student ______________
Alternate contact info_____________________________________________________
Reason for referral: (check all that apply)
Poor hygiene
Inappropriate language
Frequent absences
Limited resources: clothing, food, hygiene
Difficulty focusing
Poor social skills
Emotional Outbursts
Depressed affect, sad, crying
Social isolation
Frequent injuries
Cuts or burns, bruising
Anxiety Attack
Concerns about what they are writing
Relationship problems
Academic difficulty
Hyperactive, hard to sit still
Dietary concerns
Student wants help with alcohol/drug use
Have you discussed these concerns with the student: Yes No ?
If not, please explain why?
Briefly describe concern(s) that led to this referral. Only report the facts. Avoid making judgments
and/or opinion statements.
Thank you for taking the time to bring the needs of this student to our attention.
Call College Police (619) 388-6405 for incidents that warrant immediate attention (e.g. fights,
loud arguments, threats and crimes in progress.)
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