Counseling Referral

Counseling Referral -Concern for Student
To report emergency situations occurring on or off Rockford University Campus, call 911.
This form is for referring any current Rockford University student who may benefit from counseling services. This form is confidential and goes directly to Lang Wellness Center.

Lang Wellness Center
Monday - Friday 10am - 4pm
815-226-4083
healthcenter@rockford.edu
rockford.edu
Date

MonthDayYear
Is this report about yourself?

YesNo
Please answer the following questions as completely as possible in regards to the student of concern.
Student of Concern

First NameLast Name
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Year in School

FreshmanSophomoreJuniorSeniorGradUnknown
Please Select One

CommuterResidentUnknown
Does this concern involve:

Drug/AlcoholRelationship/Intimacy IssuesRoommate ConflictDepression/Grief/SadnessEating BehaviorsDating Violence/Domestic ViolenceStalkingSexual Assault/AbuseHomesickness/Issues at HomeAnxiety/Test Anxiety/Classroom IssuesAttendance/IsolationSelf-Destructive BehaviorOther-Please Describe Below
Description of Incident or Reason for Concern:

Please complete the following information about yourself or skip this section if you would like to remain anonymous. Lang staff does not disclose the name of the person making the referral.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
I have informed the student of this referral:

YesNo
Should be Empty:

Counseling Referral -Concern for Student