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 Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To which gender does the person being referred identify?
Agender
Male
Trans Male
Female
Gender Queer/Gender Fluid/Non-Binary
Questioning or Unsure
Trans Female
Prefer not to disclose
Other
WSU Access ID
Your WSU E-mail
example@example.com
Phone Number
*
Format: (000) 000-0000.
School Year
Referral Information
Date of Referral
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for referral
*
Referring Source
Self
Sports Administrator
Coach
Athletic Trainer
Academic Advisor
Teammate
Other
Please choose Referral Category
*
Clinical Counseling
Performance Enhancement
Consult to determine between clinical or performance.
Mandatory
Appointment Urgency?
Immediate (within 24 hours)
Urgent (within 1-3 days)
As soon as possible (within 1 week)
Non- Urgent (within 2 weeks)
Other
Preferred Appointment Days
Monday
Tuesday
Wednesday
Thursday
Friday
Submit
Should be Empty: