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Central State University
Counseling Services
Online Referral Form

Instructions: Faculty and staff using this form should consider all referrals as confidential. Complete the information requested and submit the form to Counseling Services in the Student Health Center. Thank you.

Counseling Services Telephone Numbers: Office: 937-376-6338 - Fax: 937-376-6048

Student Information

Student Last Name

Student First Name

Referral Date

Classification

Gender

Student ID Number

Local or Campus Address

Telephone

Cellular Phone

Email

Behaviors Reported or Observed

Feeling Overwhelmed?

Yes No

Tearful?

Yes No

Relationship Problems?

Yes No

Anxiety?

Yes No

Social Isolation / Withdrawal?

Yes No

Difficulty Concentrating?

Yes No

Use of alcohol or other drugs to deal with stress?

Yes No

Headaches?

Yes No

Restless / On Edge?

Yes No

Academic Problems?

Yes No

Other Issues?

Yes No

Description

Reason for Referral

Referred By?

Department?

Referrer's Phone?

Referrer's Email?


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