Referral from SHCC to UAF Community Mental Health Clinic

Student Health and Counseling Center

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043, FX: 907-474-5777| www.uaf.edu/chc
UAF STUDENT HEALTH AND COUNSELING CENTER (SHCC) REFERRAL AUTHORIZATION
Today's Date*

MonthDayYear
today's date
Student name*

First NameLast Name
Student date of birth*

MonthDayYear
Date
Student UA identification number*
8 digits and starts with a 3
Student physical address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student telephone number*
xxx-xxx-xxxx
Student email address*
example@example.com
I HEREBY AUTHORIZE UAF STUDENT HEALTH & COUNSELING CENTER TO REFER ME TO UAF COMMUNITY MENTAL HEALTH CLINIC (UCMHC). THIS INCLUDES SHARING MY NAME AND CONTACT INFORMATION LISTED ABOVE:*

Yes, I authorize this referral and consent to disclosure of my name and contact information.No, I do not authorize this referral or disclosure.
UAF Community Mental Health Clinic is located in the UAF Gruening Building on the 2nd floor. The address and telephone number are listed below:

1747 South Chandalar Drive, Gruening Building Suite #215

Fairbanks, AK 99775

Office Phone Number: (907) 474-1999.
Name of person signing this form*

First NameLast Name
Please indicate the choice below that describes your role in signing this form.*

I am age 18 or older and have legal authority to sign this form on my own behalf.I attest that I am the legal guardian of the student identified on this form and have the authority to authorize this referral.I am under the age of 18 and cannot contact my guardian to sign this form. I need to see a counselor for an urgent matter which cannot wait and assent to SHCC making this referral to UCMHC and sharing my name and contact information.
Date of Signature*

MonthDayYear
Date
Signature*

Clear
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Student Health and Counseling Center