University Counseling Center Referral Form

University Counseling Center

Referral Form

This form can be filled out by ANYONE within the TSU community. The purpose of this form is to identify students who may benefit from University Counseling Center services so that we may contact them. Please complete this form in its entirety and submit it immediately.

Student Information

Student Name*

T-Number*

Student Phone Number*

Referred By:

Name

Phone Number

Department

Does this student know that you are referring him/her to the Counseling Center?*

Select or enter value

Reason for Referral

(Please Select All that Apply)

Emotional Concerns

Select or enter value

Please give context

Life Concerns

Select or enter value

Please give context

Behavioral Issues

Select or enter value

Please give context

Other Concerns

Once a referral is received, students will be contacted the same day or the following morning if a referral is received after hours. All information shared with the University Counseling Center is confidential. After a referral is made, information regarding the student who was referred will not be shared or discussed with anyone without the student's written consent.

For questions or additional concerns, please contact the University Counseling Center at 713-313-7804.

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