Referral for Counseling Services Form : Dept of Counseling, Leadership, Adult Education & School Psychology : Texas State University

Which location would you prefer for counseling services?

San Marcos

Round Rock

Interested in: (check all that apply)

Couples Counseling

Family Counseling

Individual Counseling – Adult

Individual Counseling – Child/Adolescent (ages 9-17)

Play Therapy (counseling for children ages 3-8)

Client Name *

Age *

If client is a minor, what is the parent/guardian's name?

If the client is a minor, what is the parent/guardian's email?

Additional Client Names & Ages (for couples and family counseling; otherwise complete a new referral for individual counseling)

Briefly describe the main difficulty that you would like to address in counseling: *

How long has this issue concerned you, your partner, or your family?

Are you a Texas State University student? *

Yes

No

Are you a veteran *

Yes

No

N/A

Home Phone

May we leave a message for you regarding counseling services at this number?

Yes

No

Cell Phone

May we leave a message for you regarding counseling services at this number?

Yes

No

Best Time to Call

Email Address

Person Making Referral

Self

Other

If Other, what is your relationship to client?

If Other, what is your name?

If Other, what is your email or phone #?

Does the client know you have referred them for counseling? (if no, we cannot contact the client)

Yes

No

How did you hear about counseling services at Texas State University?

Referral for Counseling Services Form