Appointment Request Form

TSU Student Mental Health and Wellness Services Appointment Request Form

Please complete the following in its entirety.
Person making referral
Referred By:
Name
Phone Number

Area CodePhone Number
TSU Email
example@example.com
Person being referred
Full Name

First NameLast Name
T Number
TSU E-mail
Phone Number

Area CodePhone Number
Does this student know you are referring them to this program?
Reason For Referral
Reasons for referral:
Thank You for your referral To Ms. Rodriguez, LMSW, Program Coordinator1 at Texas Southern University.Ms. Rodriguez will reach out to the student being referred within 24 hours (response times may be longer on weekends and university holidays.) Please contact Ms. Rodriguez with questions at 713-313-1320.
Should be Empty:

TSU Student Mental Health and Wellness Services Appointment Request Form