Student Health Services
Referral Form for Student of Concern
Phone: 619-388-2774 Fax: 619-388-2853 Walk in office: I4-209
1. Complete Student of Concern Referral Form and email or fax form to Linda Gibbins-Croft LCSW
firstname.lastname@example.org and email@example.com. It’s best to: Save the form, fill it out then attach it to
an email. If the referral is urgent, please call our office at 619-388-2774.
2. Faculty and staff will be notified when referral form has been received.
3. 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)
q Poor hygiene q Inappropriate language
q Frequent absences q Limited resources: clothing, food, hygiene
q Difficulty focusing q Social isolation
q Poor social skills q Emotional Outbursts
q Depressed affect, sad, crying q Frequent injuries
q Odd Behavior q Cuts or burns, bruising
q Anxiety Attack q Student wants help with alcohol/drug use
q Concerns about what they are writing q Relationship problems
q Academic difficulty q Hyperactive, hard to sit still
q Dietary concerns q Social isolation
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
Thank you for taking the time to bring the needs of this student to our attention.!