BASICS Referral Form

Fill out the information below to the best of your knowledge

Title of person referring the student (coach, student, faculty, ect.) *
Name of person referring the student
Person referring email address
Name of the student being referred Name of the student being referred * First Last
Type of referral *
Students email if known
Students phone if known Students phone if known - ### - ### ####
Brief overview of why the person is being referred for Alcohol or drug related issues. *

Once a student has entered a counseling relationship their information becomes confidential, unless the student signs a release of information or is at risk to hurt themselves or someone else. Thank you