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University of Guelph Student Wellness Referral Form for External Use
Fax completed referral to Health Services: (519) 821-2308
Purpose of This Form: We are committed to arranging appropriate and timely follow-up
for University of Guelph students, however please know that there is often a waitlist for
services. The information on this form will be used by us to internally triage all referred
students to appropriate internal resources at the University as soon as possible.
Referral Source Information:
(last name, first name)
Family Physician Psychiatrist
Other MD Nurse Practitioner
Lives on campus in residence?
Date of Birth (dd/mm/year):
Will you be providing follow-up with
this person until they are seen?
If not, please explain plan:
Does the student consent to this referral? Y N
If so, please ensure to attach relevant notes
Is the student known to Counselling Services? Y N
If so, who?
Is the student known to our Student Health Services physicians and/or psychiatrists?
Y N If so, Who? ____________________________________