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Wellness Counseling Referral Form

If this is an emergency please call 911 or 65911 from a campus phone.

Please select the Campus location that you were assigned to prior to COVID-19 from the "Please select a location.." menu below.

This form should be used to refer students to our Wellness Counselor for personal and/or social concerns. The Wellness Counselor is available to work with students in a private and confidential setting for short-term counseling and referral to community resources. For Student Behaviors of Concern or low level threats that you wish to report please click Behavior of Concern.

Once the referral has been received, the Wellness Counselor will reach out directly to the student or refer them to the appropriate office. You may be contacted to provide additional information if needed.

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

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Office/Room

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Involved Person

Student Name

Select Gender Identity

Select Role

ID Number

Phone number

Email address

Home Address

Description of the problem or concern:

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Background Information

Involved Person

Description of the problem or concern:

Supporting Documentation

Submission