Counseling Request/Referral Form

1

Name of Student* This field is required.

First Name

Last Name

2

Student LOLA#* This field is required.

3

Student Email* This field is required.

example@example.com

4

Student Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

Student Phone#* This field is required.

Please enter a valid phone number.

8

What type of services are you or the individual needing services interested in?

Texting Based Counseling

Telehealth Counseling - Virtual

In-Person Counseling Sessions

Any Service

9

Additional Comments

10

Has the individual requesting/needing services had suicidal thoughts?* This field is required.

Yes

No

Maybe

Sometimes

I Don't Know

11

Does the individual requesting/needing services need additional services such a food, housing assistance, etc?* This field is required.

Yes

No

Maybe

12

Are you completing this form on the behalf of someone else?* This field is required.

YESNO

13

If you are completing this form on the behalf of someone else, please provide your name.

First Name

Last Name