Referral Form for Mandated Evaluation
Counseling and Psychological Services
This form should be completed by the Dean, Associate Dean, or Program Director when referring a student for a required evaluation.
Please send this form and the attached Authorization Form for Release of Information for Required Evaluation signed by the student to the Counseling and Psychological Services (CAPS) office.
When both forms have been completed and submitted to the CAPS office, the Dean's office representative or the student may call CAPS to schedule the evaluation.
Name of Student: ________________________________________
Referred by: _____________________________________________
Date of Referral: __________________________________________
Reason(s) for Referral Please check all that apply:
( ) Academic Problems
( ) Suspected impairment due to alcohol and/or drug use or abuse
( ) Professionalism Problems
( ) Concern about student mental health
( ) Evaluation for ability to function in clinical settings
( ) Honor Code violation
( ) Other:____________________________________
( ) Student request of Leave of Absence due to mental health issues
Comments relating to the referral:
Signature of Dean, Associate Dean, or Program Director