Counseling Referral
Please fill out all sections of the referral form. If you are referring a student athlete, please also list your email. Your email is required only so you can receive confirmation that your submission was received. All referrals will remain confidential and will only be received by the Health & Wellness Counselor.
Referred By:
*
Coach
Teammate
Trainer
Professor
Advisor
Self-Referral
Other
Your E-mail
*
Student Athlete Contact Information
If you are submitting a referral for yourself or someone else, please make sure to list either the student's phone number or email.
Student Name
*
First Name
Last Name
Phone Number
E-mail
example@example.com
Team
*
Academic Year
*
Reason for Referral
Please note the referral site is not live monitored. For immediate concerns about student safety please contact Campus Security (215-242-7777) or 988.
Please briefly describe the reason for referral
*
Is this student's well-being an immediate concern?
*
Yes
No
Preferred days/time for appointment *If you are submitting for someone else write N/A*
*
Submit
Should be Empty: