Referral Form for Mandatory Evaluation

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: ________________________________________  

College: ________________________________________________

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

________________________________                           

Signature

________________________________                           

Title

________________________________                           

Date