Faculty/Staff Service Request Form
I understand and agree that my name may be provided to the student as the referral source. I understand that this form is not intended for immediate, high risk, crisis intervention. I understand that all calls and scheduling are coordinated at the main Student Counseling Center location on the Lake Worth Campus.
Referral Source Acknowledgment Signature
Name of requestor
First Name
Last Name
Role at college
PBSC Email
example@example.com
Preferred Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Support Request
I would like the Student Counseling Center to contact a student in need
I have notified the student of this referral and the student agrees
The student DOES NOT report being at risk of harming self or others
The student DOES report being at risk of harming self or others and 911 has been contacted
The student DOES report being at risk of harming self or others and Campus Safety has been notified
This request has been made during hours that the Student Counseling Center is closed. If the student is suicidal Campus Safety and/or 911 has been notified. Please provide details of report in comment section below.
Student Name
First Name
Last Name
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student ID
Student Email
example@example.com
Student location if known
Reason for contact request (be as descriptive as possible)
Signature of referral source
Submit
Should be Empty: