WLA Student Wellness Self Referral Form

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Please fill out this form if you would like a member of the Wellness Team to contact you regarding individual counseling services.

Email *

Date of Referral: *

YYYY

Student Name *

Advisor's Name: *

Reasons for Referral (check all that apply): *

Academic Related Stress or Concern (e.g. disagreement with teacher, failing grade, tutoring)

Peer Related Stress or Concern (e.g. arguments, bullying or harassment, difficulty making friends)

Emotional Stress or Concern (e.g. feelings of depression, anxiety, anger, lack of self-control)

School (e.g. tardiness/absences, study skills, time management, uniform or clothing needs)

Substance Use/Abuse (e.g. drugs--illegal or prescription, alcohol, tobacco)

Emotional Crisis (e.g. suicidal thoughts, thoughts to self harm, thoughts to harm others)

Concerns at home (e.g. arguing with parents, divorce or separation of caregivers, homelessness/running away, loss of loved one)

Other:

Required

Level of Referral: *

Mild (I am completely in control and able to be successful in class)

Elevated (I am having a difficult time remaining in control and need assistance soon)

Severe (I am not in control and I am not productive in class)

Extreme (I need help now. I am not in control and I am not safe in class)

Please give a brief description of why you are seeking services: *

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