East Carolina University Brody School of Medicine

East Carolina University Brody School of Medicine

Office of Student Development and Academic Counseling Brody 4N-51

Student Referral Form

Please provide as much information as possible regarding the student you are referring for services and deliver the form via email to Dr. Cassandra Acheampong at , by fax to 252-744-0722, or by mail/ person to the Office of Student Development and Academic Counseling, 4N51 Brody Medical Sciences Building, Mail Stop 707.

Name of faculty/staff member making the referral:______

Relationship to student:______

Date of the referral:______

Name of student being referred:______

Student’s status:  M1  M2  M3  M4  PhD ______(program)  Resident MD : ______(program)

Action you would like to have taken (please check all that apply):

o  Request counseling staff contact the student for an appointment

o  Have spoken to student and requested that student contact office for an appointment

o  No action necessary, referral being made to alert counseling staff of concerns

o  Other: ______

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Please describe primary concerns about student:

______

______

______

______

______

______

______

______

______

______

Thank you for your referral to the Office of Student Development and Academic Counseling. Further contact regarding this student will be made only with the student’s expressed written permission.

4/18/13

Phone: 252-744-2500 Fax: 252-744-0722 http://www.ecu.edu/bsomcounseling/