Care Referral Form HomePersonal CounselingAppointmentsCare Referral FormStudent Support ServicesContact InformationApps & Online ResourcesMental Healthy Newsletter Client Name(Required) First Last The name of the person you're referring for Mental Health & Counseling Support.Client Phone NumberClient Email Is this referral for yourself or someone else?(Required) Myself Someone Else Is this person aware of the referral?(Required) Yes No Has this person asked for: information about counseling or mental health services? an appointment to initiate help? someone to contact them to offer help? something else (explain below) Something else (please explain)(Required)Name of Person Making the Referral(Required) First Last Please enter your information as a means of contact if needed.Consent(Required) I agree to the privacy policy.By providing the information above, you agree to the understanding that the information on this form is confidential, can only be used for the intended purpose, and will not be shared with the referred party unless requested.Please rate the urgency of this request by indicating the appropriate number:(Required)1 (Not Urgent)2345 (Moderately Urgent)678910 (Very Urgent)Reason for referral:(Required) Mental health concerns Marital separation/divorce Emotional well being Abuse Suicide/self harm Friends/peer relationships Family violence Bullying Learning difficulties Learning support/educational issues Academics Grief and/or loss Anger Adjustment issues (difficulty adapting to major life changes) Behavioral concerns Accommodation issues Parental/carer concerns Career/vocational Parenting/relationship issues Other Other (please explain)Please provide further information regarding this referral:(Required) Dramatic change in behavior Worries/anxious/nervousness Sadness Inverts/reverses numbers or letters Withdrawn/isolated Anger/irritability Fighting Bullying Making threatening or intimidating remarks Defiant Unable to follow directions Hurts self Destructive Sexually acting out Drop-out risk Easily distracted Alcohol/drug use Disruptive Low motivation/effort Stress Bizarre thoughts or behaviors Excessive or uncontrollable crying Trouble adjusting to new living situation Reports abuse (physical, sexual, emotional) Suffered recent loss (including parent, divorce, job, etc.) Other Other (please explain):Have you discussed concerns with this person?(Required) Yes No If so, what was the outcome?Is there anything else you'd like me to know?
