WSU Counseling Referral Form

WSU Counseling Referral Form

Mental Health & Performance Referral

Wayne State University Athletic Department
STUDENT-ATHLETE DEMOGRAPHIC

Please use this form to request appointments with a member of Wayne State University 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?
WSU Access ID
Your WSU E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
School Year
Referral Information
Date of Referral

MonthDayYear
Date
Reason for referral
Referring Source
Please choose Referral Category
Appointment Urgency?
Preferred Appointment Days
Should be Empty: