Haskell Indian Nations University
Student Assistance Program (S.A.P.)
Referral Form
Note: Please use this form for referring students for counseling. Submit the completed form to the Counseling
Services Center. The Counseling Supervisor will review and assign a counselor. Notication of the assignment
will follow.
Student’s Name: Date of Referral:
Referred by:
Dept: Telephone:
Nature of referral (check all that apply):
Possible Health Problem Possible Emotional Problem
Suspected Chemical Abuse Abnormal Behavior/Conduct
Academic Problems Other Concerns, please describe below
Brief Narrative of Observation:
Additional Background Information (i.e. what contact/counseling have you had with the individual; has the
individual had previous discipline write-ups?): Do you have any knowledge whether this individual has
had any previous discipline write-ups?
Recommended Counseling Need (please check, if applicable):
Personal Issues Academic
Below this line for Ofce Use Only
Counseling Referred to: Date Referred:
Date Received and Logged in the ofce:
Date Reviewed by the Counseling Supervisor:
Level of Counseling Intervention Recommendation by the Supervisor (I, II, III):
Counseling Supervisor’s Comment’s About this Referral:
