Application: Counseling and Testing Services

REFERRAL FORM

Instructions: The referring person completes Part 1; the Director of Counseling Services completes Part 2; the assigned counselor completes Part 3, maintains a case file, and completes part 4 as indicated.

* Fields required to be filled.

PART 1.

* Student's Name:
Last:
First:

SS#: (enter last four digits)

Residence:

Telephone #:

* Referring Person's Name: Date:

E-mail Address:

* Reason for Referral:

PART 2.

Assigned to: Date:

PART 3.

Counseling Activity

__ A. Individual Counseling

__ B. Educational Sessions

__ C. Referral for Intensive Individual Counseling

PART 4. OUTCOME:

Successfully Completed?

___ Yes    Date Started: ____________ Date Completed: ____________
___ No

Comments:

THIS COMPLETED FORM WILL BE SENT TO:

Ms. Millercin Fields Weeks, Director
Counseling Services
Benedict College
1600 Harden Street
Columbia, South Carolina 29204