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Student Referral Report


This form is for FACULTY USE ONLY. Students seeking a counseling appointment may do so using the information under the Counseling Services link at the right.
Choose the appropriate section for your referral:

This referral is from:
Instructor name
Instructor email
Instructor phone
Regarding the following student:
Student name
SID
Course Title
Would you like a Counselor to update you on the status of your referral:
Is student currently attending class?

Please summarize the situation: