Referral Feedback Form

To:

From:

Date:

Regarding:

Thank you for referring the above student for evaluation or counseling. The status of the referral is as follows:

______student has not responded to appointment requests

______evaluation in progress

______evaluation completed

______student is receiving individual therapy

______student is receiving group therapy

______student is being seen in family therapy

______student declined counseling services

______student was referred for outside evaluation/treatment

______closed due to missed appointments by student

______student’s difficulties appear to be resolved

______parental consent denied

______student is receiving mental health services from another provider

______other: ______

Comments:

______

______

______

______

______

Please do not hesitate to contact me should you have any questions or comments.