Referral Source Email Address Phone Number______

Referral Source

Name______Office______

Referral Source email address phone number______

Student being referred ___ ID # ______

Reason for Referral______

______

AuthorizationtoExchangeConfidentialInformation:Social Workers’andCounselors’ethicalguidelinesrequirea signedreleaseofinformationbeforetheycandiscussanyinformationaboutaclient.Pleasehavethestudentreadand signbelowiftheyagreetoallowcommunicationregardingthisreferral.Acopyofthissignedformshouldbekeptin thereferringsource’sfile,acopyshouldbeprovidedtotheOffice of Counseling and Disability Services,andacopyshouldbeprovidedtothe studenttobringtotheinitialappointment.Thisdocument,whensignedbythestudent,willallowlimited communicationbetweenthesocial worker/counselorandthereferringsource.Onlyinformationconfirmingthatthestudentfollowed thereferralwillbeprovided.Contentofcounselingsessionswillnotbesharedwiththereferringperson.

NOTE:A studentdoesnotneedareferralforminordertoreceivetreatmentattheCounselingCenter.Thisformisonlya facilitationdeviceformakingefficientreferrals.

Areferraltocounselingisanopportunitytogrow,tochangeattitudes,habits,and/orbehaviorsthatareproblematic. Counselingmayalsoprovidesupportneededtoovercomenegativesituationsorfeelingsthataredisruptingyourlife.

Afterreferral,theclientisresponsibleforkeepingtheinitialappointmentattheSSU Office of Counselingand Disability Servicesandwillbringthe referralformtotheofficeatthattime.Thesocial worker/counselorwillperformanassessmentduringanintakeinterview,andthe client,inconsultationwiththesocial worker/counselor,willsetappropriategoalsforcounseling.Counselingsessionswillcontinueuntil suchtimethatthe social worker/counselorandclientmutuallyagreethatadequateprogresshasbeenmadetowardtheclient’sgoals.

I______havereadtheparagraphaboveandIgivethereferringsourceandthestaff

oftheOffice of Counseling and Disability Servicespermissiontocommunicateregardingmyfollowthroughonthisreferral.

SignatureofClient ______Date______SignatureofReferralSource______Date______

**Note:Astudentshouldonlysignthisformwhentheyarewillingtogivepermissionforthereferringsourcetoknow thattheyhavefollowedthroughwiththereferral.

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ForOffice of Counseling and Disability Services Staff UseforReport toReferring Source

Clientkeptinitialappointment

Clientdidnotkeepinitialappointment

Social Worker’sorCounselor’sSignature ______Date______