Panola College Mental Health Contact Form
Received by Dr. Angela Lucas
Student Details:
Student's Full Name
*
First Name
Last Name
Student Phone Number
Format: (000) 000-0000.
Student E-mail
*
example@example.com
Reason for referral (optional)
Who is making the referral
Student (self)
Faculty/Staff member
If referral is made by faculty member, please list faculty/staff member's name below:
Submit
Should be Empty: