Central State University 1887, registered trademark

Central State University
Counseling Services
Referral Feedback 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

Date of Referral?


Behaviors Reported or Observed

Feeling Overwhelmed?

Yes No


Yes No

Relationship Problems?

Yes No


Yes No

Social Isolation / Withdrawal?

Yes No

Difficulty Concentrating?

Yes No

Use of alcohol or other drugs to deal with stress?

Yes No


Yes No

Restless / On Edge?

Yes No

Academic Problems?

Yes No

Other Issues?

Yes No

Post Referral - Please choose one selection from below and add comments.

Positive Change?

No Change?

Negative Change?

No Contact?


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