REFERRAL FORM FOR SUBSTANCE ABUSE-RELATED COUNSELING

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					                                   WESTFIELD STATE COLLEGE
                    REFERRAL FORM FOR SUBSTANCE ABUSE-RELATED COUNSELING


Referred by:
Name                                                        Date




Student’s Name                                              Sex    M   F             DOB          Age




Campus Address                                                             Campus Phone




Referred For
Please check one                Substance Abuse Issues (Self)          Substance Abuse – Related Issues


Please check one                 Emergency                    Urgent                    Non-Emergency




Please briefly describe circumstances/reason for referral




Please describe follow-up contact desired from the Substance Abuse Counselor to referral Source




Return to: Brian Cahillane, Counselor, Box 187, Parenzo Hall




To be filled out by counselor
Action Taken




Signature _____________________________________________________