ࡱ> 8:7Q bjbj 4ee t/////   2444444$'HX     X//m  //2 2/I 0%j%%,       XXj       %          : CONFIDENTIAL University of Louisiana at Monroe Self-Development, Counseling, and Special Accommodations Center Non-Emergency Referral Form Referring Source: __________________________________________________________________ Name Department Referral Source e-mail address: _______________ Phone number: _________________ Student being referred: _______________________________ CWID# ______________________ Reason for referral: _________________________________________________________________ Authorization to Exchange Confidential Information: Ethical and legal guidelines require a signed release of information before any information can be discussed about a client of the ɫAV Self-Development, Counseling, and Special Accommodations Center. Please have the student read and sign below only if an agreement is made to allow communication regarding this referral. A copy of this signed form should be faxed (342-5228) or email to a member of the Centers staff. A copy should be provided to the student to bring to the initial appointment. This document, when signed by the student, will allow limited communication between the ɫAV Self-Development, Counseling, and Special Accommodations Center and the referring source. Only information confirming that the student followed the referral will be provided. Content of counseling sessions will not be shared with the referring person. NOTE: A student does not need a referral form in order to receive treatment at the ɫAV Self-Development, Counseling, and Special Accommodations Center. This form is only a facilitation device for making efficient referrals. The referring source is always welcome to call the Center (342-5220) to provide any additional information that you believe would be helpful or with any questions or concerns. If this is a life-threatening emergency, call the University Police Department at 1-911 from a campus phone or 342-5350 from any other phone. If medical attention is needed and the crisis occurs off-campus, call 911. 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