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    Faculty Staff Referral Form Rev 2014

    Uploaded by

    Shaiza Mae Ligayan
    Faculty

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Faculty Staff Referral Form Rev 2014

    Uploaded by

    Shaiza Mae Ligayan
    10 views1 page
    Faculty

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Faculty

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views1 page

    Faculty Staff Referral Form Rev 2014

    Uploaded by

    Shaiza Mae Ligayan
    Faculty

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    UNIVERSITY COUNSELING AND WELLBEING CENTER REFERRAL

    Name of Person Making Referral __________________________________ Date _______________


    Referrer Phone # ____________________ Referrer E-mail _____________________________________
    Name of Student _____________________________ Program and Year _______________________

    Has the student expressed intent to harm him or herself? ______No ______ Yes
    f yes, please seek professional assistance immediately:
    Weekdays 8:30-4:30 contact the UCWC at 412-396-6204;
    After hours contact the UCWC Counselor on Call via DU Police at 412-496-2677; 24
    hours a day contact re:Solve Crisis Network at 1-888-796-8226.

    Has the student expressed intent to harm others? ______No ______ Yes
    If yes, please contact DU Police at 412-496-2677.
    For Campus Safety concerns contact the Campus Community Risk Team at 412-849-4306.

    Which difficulties might this student be experiencing? (Please mark issues you are concerned about. It
    is not important for you to inquire about each issue; we will provide a comprehensive assessment.)

    ______ Poor academic performance ______ Poor attendance


    ______ Inappropriate classroom behavior ______ Not performing well
    ______ Excessive anxiety/ panic/ worry ______ Lack of motivation
    ______ Easily upset/irritable ______ Problems with concentration
    ______ Trauma or loss ______ Relationship problems
    ______ Shyness/ lack of confidence ______ Aggressive behavior
    ______ Hallucinations ______ Strange/bizarre speech or behavior
    ______ Legal problems ______ Substance abuse
    (If Substance abuse is the primary issue, refer first to Dan Gittens, DU CARES Coordinator (412) 396-5834).
    ______ Other: _________________________________________________________________________
    Is this student mandated by your program to participate in an assessment?
    ______No ______Yes If yes, what are the consequences of refusal to participate or to follow our
    recommendations?
    _____________________________________________________________________________________

    Please describe the behavioral change you would like the student to demonstrate. In other words, how
    could one observe that this student was making progress toward necessary goals? If needed, describe
    further on the back of this form.

    ______________________________________________________________________________________________
    TO BE COMPLETED BY THE STUDENT:
    May the University Counseling and Wellbeing Center contact you directly: Yes_____ No_____ May
    we tell the person who referred you that you are attending: Yes_____ No_____

    Student Signature: ____________________________________________________ Date: ____________________

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