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?

AgenderMaleTrans MaleFemaleGender Queer/Gender Fluid/Non-BinaryQuestioning or UnsureTrans FemalePrefer not to discloseOther
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*

SelfAthletic TrainerSport AdministratorAcademic AdvisorCoachTeammateOther
Appointment Urgency?*

As soon as possible (within 1 week)Non-Urgent (Within 2 weeks)Urgent (Providers Contacted)Other
Please choose Referral Category*

Clinical CounselingPerformance EnhancementConsult to determine between clinical or performance
Preferred Appointment Days

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Your Availability: Please check all that apply:

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

Clear
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