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.


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PART 1.

* Student's Name:
Last:
First:

SS#: (enter last four digits)

Residence: , Telephone #:

* Referring Person's Name:

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

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