{"id":1388,"date":"2021-08-09T18:20:40","date_gmt":"2021-08-09T22:20:40","guid":{"rendered":"https:\/\/wwwcp.umes.edu\/counselingservices\/?page_id=1388"},"modified":"2021-09-26T20:38:14","modified_gmt":"2021-09-27T00:38:14","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/wwwcp.umes.edu\/counselingservices\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>Counseling Services<br>REFERRAL FORM<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-left wp-block-paragraph\"><strong>Instructions<\/strong>: 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, 2<sup>nd<\/sup>Floor \u2013 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 student\u2019s assistance. Parents will be notified only with the student\u2019s permission, and\/or if the student has any suicidal \/homicidal ideations, or if someone has caused them any harm.<\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1445 forminator-design--default forminator-enclosed forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1445\" data-uid=\"6a57bd4a36dc7\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-1445\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1445 forminator-design--default forminator-enclosed forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"1445\"\r\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"enclosed\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a57bd4a36dc7\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a57bd4a36dc7\" id=\"forminator-field-name-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Student Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_6a57bd4a36dc7\" id=\"forminator-field-name-4_6a57bd4a36dc7-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a57bd4a36dc7\" id=\"forminator-field-date-1-picker_6a57bd4a36dc7-label\" class=\"forminator-label\">Date of Referral<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a57bd4a36dc7\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a57bd4a36dc7\" id=\"forminator-field-text-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Classification<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a57bd4a36dc7\" id=\"forminator-field-text-2_6a57bd4a36dc7-label\" class=\"forminator-label\">Student ID#<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a57bd4a36dc7\" id=\"forminator-field-address-1-street_address_6a57bd4a36dc7-label\" class=\"forminator-label\">Local\/Campus Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a57bd4a36dc7\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a57bd4a36dc7\" id=\"forminator-field-text-3_6a57bd4a36dc7-label\" class=\"forminator-label\">Sex<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a57bd4a36dc7\" id=\"forminator-field-phone-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Telephone #s<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a57bd4a36dc7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a57bd4a36dc7\" id=\"forminator-field-text-4_6a57bd4a36dc7-label\" class=\"forminator-label\">Gender<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a57bd4a36dc7\" id=\"forminator-field-name-2_6a57bd4a36dc7-label\" class=\"forminator-label\">Emergency Contact<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a57bd4a36dc7\" id=\"forminator-field-phone-2_6a57bd4a36dc7-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a57bd4a36dc7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a57bd4a36dc7\" id=\"forminator-field-text-5_6a57bd4a36dc7-label\" class=\"forminator-label\">Relationship<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a57bd4a36dc7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a57bd4a36dc7-label\" class=\"forminator-label\">Behaviors reported or observed<\/span><label id=\"forminator-field-checkbox-1-1-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-1-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Academic problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"academic-problems\" id=\"forminator-field-checkbox-1-1-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-1-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Academic problems<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-2-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Afraid\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"afraid\" id=\"forminator-field-checkbox-1-2-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-2-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Afraid<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-3-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Anxiety\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"anxiety\" id=\"forminator-field-checkbox-1-3-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-3-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anxiety<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-4-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Bullied\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"bullied\" id=\"forminator-field-checkbox-1-4-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-4-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bullied<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-5-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Difficulty concentrating\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"difficulty-concentrating\" id=\"forminator-field-checkbox-1-5-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-5-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Difficulty concentrating<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-6-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Domestic Violence\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"domestic-violence\" id=\"forminator-field-checkbox-1-6-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-6-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Domestic Violence<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-7-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Drastic change in appearance\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"drastic-change-in-appearance\" id=\"forminator-field-checkbox-1-7-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-7-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Drastic change in appearance<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-8-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Feeling overwhelmed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"feeling-overwhelmed\" id=\"forminator-field-checkbox-1-8-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-8-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Feeling overwhelmed<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-9-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Harassed\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"harassed\" id=\"forminator-field-checkbox-1-9-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-9-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Harassed<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-10-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Homeless\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"homeless\" id=\"forminator-field-checkbox-1-10-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-10-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Homeless<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-11-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Physically ill\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"physically-ill\" id=\"forminator-field-checkbox-1-11-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-11-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Physically ill<\/span><\/label><label id=\"forminator-field-checkbox-1-12-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-12-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Relationship problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"relationship-problems\" id=\"forminator-field-checkbox-1-12-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-12-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Relationship problems<\/span><\/label><label id=\"forminator-field-checkbox-1-13-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-13-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Restless\/on edge\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"restlesson-edge\" id=\"forminator-field-checkbox-1-13-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-13-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Restless\/on edge<\/span><\/label><label id=\"forminator-field-checkbox-1-14-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-14-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Sadness \/Depression\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"sadness-depression\" id=\"forminator-field-checkbox-1-14-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-14-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sadness \/Depression<\/span><\/label><label id=\"forminator-field-checkbox-1-15-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-15-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Social isolation\/withdrawal\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"social-isolation\/withdrawal\" id=\"forminator-field-checkbox-1-15-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-15-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Social isolation\/withdrawal<\/span><\/label><label id=\"forminator-field-checkbox-1-16-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-16-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Tearful\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"tearful\" id=\"forminator-field-checkbox-1-16-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-16-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tearful<\/span><\/label><label id=\"forminator-field-checkbox-1-17-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-17-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Un-motivated\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"unmotivated\" id=\"forminator-field-checkbox-1-17-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-17-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Un-motivated<\/span><\/label><label id=\"forminator-field-checkbox-1-18-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-18-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Use of alcohol or other drugs\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"use-of-alcohol-or-other-drugs\" id=\"forminator-field-checkbox-1-18-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-18-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Use of alcohol or other drugs<\/span><\/label><label id=\"forminator-field-checkbox-1-19-6a57bd4a36dc7-label\" for=\"forminator-field-checkbox-1-19-6a57bd4a36dc7\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"other\" id=\"forminator-field-checkbox-1-19-6a57bd4a36dc7\" aria-labelledby=\"forminator-field-checkbox-1-19-6a57bd4a36dc7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a57bd4a36dc7\" id=\"forminator-field-textarea-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Unusual behaviors (explain)<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a57bd4a36dc7\" id=\"forminator-field-textarea-2_6a57bd4a36dc7-label\" class=\"forminator-label\">Reason for referral<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1445__field--select-1_6a57bd4a36dc7\" id=\"forminator-form-1445__field--select-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Was the student informed?<\/label><select  id=\"forminator-form-1445__field--select-1_6a57bd4a36dc7\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1445__field--select-1_6a57bd4a36dc7-label\"><option value=\"yes\"  data-calculation=\"0\">Yes<\/option><option value=\"no\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a57bd4a36dc7\" id=\"forminator-field-textarea-3_6a57bd4a36dc7-label\" class=\"forminator-label\">Actions taken prior to referral<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a57bd4a36dc7\" id=\"forminator-field-textarea-4_6a57bd4a36dc7-label\" class=\"forminator-label\">Any past history of psychiatric services<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6a57bd4a36dc7\" id=\"forminator-field-textarea-5_6a57bd4a36dc7-label\" class=\"forminator-label\">Medication (if known)<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a57bd4a36dc7\" id=\"forminator-field-text-6_6a57bd4a36dc7-label\" class=\"forminator-label\">Drugs<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a57bd4a36dc7\" id=\"forminator-field-text-7_6a57bd4a36dc7-label\" class=\"forminator-label\">Alcohol<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a57bd4a36dc7\" id=\"forminator-field-text-8_6a57bd4a36dc7-label\" class=\"forminator-label\">Substance Use<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a57bd4a36dc7\" id=\"forminator-field-textarea-6_6a57bd4a36dc7-label\" class=\"forminator-label\">Medical Concerns<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a57bd4a36dc7\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a57bd4a36dc7\" id=\"forminator-field-name-3_6a57bd4a36dc7-label\" class=\"forminator-label\">Referred by<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a57bd4a36dc7\" id=\"forminator-field-text-9_6a57bd4a36dc7-label\" class=\"forminator-label\">Department<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6a57bd4a36dc7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_6a57bd4a36dc7\" id=\"forminator-field-phone-3_6a57bd4a36dc7-label\" class=\"forminator-label\">Telephone #<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_6a57bd4a36dc7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a57bd4a36dc7\" id=\"forminator-field-email-1_6a57bd4a36dc7-label\" class=\"forminator-label\">Your Email<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a57bd4a36dc7\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"captcha-1\" class=\"forminator-field-captcha forminator-col forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"inline\" data-sitekey=\"6LcCCBQdAAAAAP73y91aYkTmlJsRh0SvZzWKMuhk\" data-size=\"invisible\"><\/div> <\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Form<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"ce11ee3e88\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/counselingservices\/wp-json\/wp\/v2\/pages\/1388\" \/><input type=\"hidden\" name=\"form_id\" value=\"1445\"><input type=\"hidden\" name=\"page_id\" value=\"1388\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/wwwcp.umes.edu\/counselingservices\/referral-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>Counseling Services Telephone Numbers: Office: 410-651-6449 \/ Fax: 410-651-7752<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Counseling ServicesREFERRAL 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 \u2013 Suite 2260. You may also fax referrals by using the fax number provided on the&#8230;<span class=\"cpschool-read-more-link-holder\"><a class=\"btn btn-basic cpschool-read-more-link\" href=\"https:\/\/wwwcp.umes.edu\/counselingservices\/referral-form\/\">Read more <span class=\"sr-only\">Referral Form<\/span><\/a><\/span><\/p>\n","protected":false},"author":21,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"folder":[],"class_list":["post-1388","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/pages\/1388","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/users\/21"}],"replies":[{"embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/comments?post=1388"}],"version-history":[{"count":0,"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/pages\/1388\/revisions"}],"wp:attachment":[{"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/media?parent=1388"}],"wp:term":[{"taxonomy":"folder","embeddable":true,"href":"https:\/\/wwwcp.umes.edu\/counselingservices\/wp-json\/wp\/v2\/folder?post=1388"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}