Referral Form

Counseling Services
REFERRAL FORM

Instructions: Faculty and staff using this form should consider all referrals as confidential. Complete the information requested, if hand delivered place in a sealed envelope and forward to Counseling Services in the Student Development Center, 2ndFloor โ€“ Suite 2260. You may also fax referrals by using the fax number provided on the bottom of this form. Please try to complete this referral form with the studentโ€™s assistance. Parents will be notified only with the studentโ€™s permission, and/or if the student has any suicidal /homicidal ideations, or if someone has caused them any harm.

Behaviors reported or observed

Counseling Services Telephone Numbers: Office: 410-651-6449 / Fax: 410-651-7752