Cincinnati State eForms - Counseling Services Referral Form

Counseling Services Referral Form

Thank you for your referral. Counseling Services provides free and confidential personal and career counseling, crisis intervention for students, access to community resources, and consultation for College faculty and staff members. Our services are designed to help students understand themselves and their difficulties, and ultimately make healthy choices for their lives. Services are provided in a nurturing environment where similarities and differences among people are recognized, respected, and honored. If you do not click Preview & Confirm or Save & Submit Later within 2 hours, your data will be lost.

Attention!

If you do not click Preview & Confirm or Save & Submit Later before the timer expires, your data will be lost.

Your Information

First Name*

Middle Name

Last Name*

Suffix

College ID*

E-mail*

Fields with * are required.

Student Name

Student ID Number

Student's Phone Number

Student's Email Address

Your Phone Number ( the person making this referral)*

Personal/Crisis/Consultation: Please State the reason(s) for your referral*

Please indicate the seriousness of your concerns (in your perception). *

Have the police been involved in the situation?*

If yes, please indicate the name of the officer.