Counseling Referral Form

Mental Health & Performance Referral

Michigan State University Athletic Department
STUDENT-ATHLETE DEMOGRAPHIC
Please use this form to request appointments with a member of Michigan State Athletic Wellness Team.

If this is an medical emergency or you are in need of immediate assistance, please call 911 or go to your nearest hospital emergency room.
Student -Athlete

First NameLast Name
DOB

MonthDayYear
Date
To which gender does the person being referred identify?
MSU ID
Your MSU E-mail
School Year
Phone Number

Area CodePhone Number
Sport
Current Michigan State Address

Street Address

Unit & Apt. #

CityState / Province

Postal / Zip Code
Referral Information
Date of Referral

MonthDayYear
Date
Reason for referral
Referring Source
Appointment Urgency?

Other
Please choose Referral Category
Preferred Appointment Days

Your Availability: Please check all that apply:

Do you have any specific provider requests?
Male vs. female, telehealth or office?
Signature
Emergency Resources

If you or anyone you know are experiencing an immediate life-threatening experience, please utilize the following services in the event providers are unavailable.

·         911- all emergencies

·         988-Suicide and Crisis Lifeline

·         Text either “Home”, “START”, or “HELLO” to 741741-Crisis Text Line

·         (800) 799-7233-National Domestic Violence Hotline

·         (800) 656-4673-National Sexual Assault Hotline
Student-Athlete Wellness Address

771 Chestnut Road East Lansing, MI 48824
Should be Empty:

STUDENT-ATHLETE DEMOGRAPHIC