San Joaquin Delta College Counseling Services
To arrange a meeting with a campus counselor, faculty and staff are encouraged to refer students in need of
counseling services with this referral form. We strongly recommend that you speak to the student first
regarding your concern, and then inform him/her of the referral to Counseling Services.
If there is an
emergency and /or the student is in crisis, please call Campus Police immediately at 954-5000 or dial
911 from any campus phone.
Thank you in advance for your concern for this student.
Date:
Referred By:
Department:
Phone/Ext:
Student’s Name:
Preferred Student Contact Method:
Delta ID#:
Home Phone: Cell Phone:
If contacted by phone, may we leave a message? Yes No
Email Address:
Reason(s) For Referral:
(Please explain the presenting problem and share your observations.)
Check this box to indicate if student declined counseling services that have been offered.
Faculty/Staff Signature: Date:
*If you have a special circumstance, complete this section to request a counselor to visit your
location: (ex: death of a classmate/instructor, witness to a violent/traumatic act, etc.)
Faculty Office Faculty Classroom Preferred Counselor
Date: Time: Location:
ACTION TAKEN: (COMPLETED BY COUNSELOR/MANAGER and return to CSS Dean)
Counselor/Manager Name: Date:
Revised 3/10/2020
CONFIDENTIAL COUNSELING REFERRAL FORM
Please fill out this form and return to San Joaquin Delta College Counseling Center in
DeRicco building 2
nd
floor, office 234, Attn: Dean of Counseling & Special Services
Phone: (209) 954-5151, ext. 6279 or ext. 6278
click to sign
signature
click to edit
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