Case Management Resources and Referrals

Students Name
Preferred Method of Contact
Can the Case Manager leave a voicemail/send an email regarding this referral?
Student Lives:
Students Address (where student is currently living)
Who is Referring?
Referral's Name
Please be as thorough as possible. This could include needing campus/community resources, assistance accessing known resources, assistance with insurance, assistance navigating systems, etc. If it is hard to identify what is needed please provide examples and information regarding the concern(s).
Are there any Safety Concerns?
Please be advised: submission of this form does not guarantee services, but every attempt will be made to connect students to the appropriate resources to provide support and assistance to overcome the daily challenges they may face. This form is confidential and in accordance to HIPPA and FERPA standards student information may not be able to be discussed with the referring person or the student’s support network without the written consent of the student. By submitting this form you acknowledge understanding that Case Management Services are not counseling services . The purpose of this referral is to support the student in identifying and accessing appropriate services. If there is a concern of immediate danger to self or others please dial 911 or contact Mobile Crisis -1-800-422-0045. Case Management is not an appropriate resource for immediate crisis concerns.(Required)