Assistance Request

To be completed by faculty member (please print this form for your use).

Faculty member _____________________________ Course ________________.

Telephone No. ________________ E-mail address ___________________ Date __________.

Student's Name ______________________________ SSN __________________.

Student is being referred to (specify a counselor if you wish) ________________________.

Comments (optional):

 

Note to student:

To make an appointment for counseling, please bring this form to the counseling office.

For counseling office use only:

Appointment set up (date) ______________ with (counselor) _______________________.

Today's date ______________ Hand-delivered to counselor (date) _______________.

For counselor use only:

Faculty member contacted on (date) ______________.

Summary of concern/plan of action: