Counseling Resource Center

Please use this form to let the Counseling Center know about a student for whom you have concern and would like us to check in with them.

You may also call us directly at 478-476-5167. Please have the below information available when you call.

Please note: When we call to check in with the student, we will let them know that you have expressed concern about them and have asked us to contact them. If you do not want your name used, please indicate it on the form

Today's date: This question requires a valid date format of MM/DD/YYYY.

1. Please provide your contact information.

Your Name: *This question is required.

Your telephone number: *This question is required.

2. Please provide the student's information.

Student's Name: *This question is required.

Student's telephone number: *This question is required.

Student's ID #: *This question is required.

Student's Email Address: *This question is required.

3. Reason for referral / Presenting concerns *This question is required.

4. Select all of the following that apply *This question is required.

Please contact me if the Counseling Center makes contact with the student (with the student's permission).
Please contact me if the Counseling Center is unable to make contact with the student.
I do not need a reply.
I do not want my name used.

Counseling Resource Center - Referral Form