Referral For Counseling

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Student Infomation

*First Name:

*Last Name:

*Date of Birth

*Address

*City

*State

*Zipcode

*Contact Number:

*Gender

*Ethnicity

*International Student

YesNo

*Athlete

YesNo

Team

*Email Adress:

*Student ID#

Pronouns

Medications

Name Medication and for what condition

*Symptoms & Behaviors

Referral Source

*Name

Contact Number

*Email Address

Referrals are forwarded to:counselingcenter@flcoastline.com and shall receive a response within 48 hours. If a student is crisis, it is best to contact the counseling center to engage student as soon as possible. Of course crisis situations requiring emergany assistance, 911 is the contact

Academic Failure
Adjustment challenges
Alcohol Problems
Anxiety/Panic
Appetite Changes
Depressed mood
Disturbing Thoughts
Drug Problems
Eating Problems
Family Problems
Health Problems
Hyperactive
Impulsivity
Isolation
Manic Mood
Physical Aggressions
Physical Pain/Discomfort
Relationship Problems
Scared
Self-care Deficit
Sleeping Pattern Changes
Social Withdrawal
Suicidal Ideations/Attempt
Thoughts of harming self
Thoughts of harming others
Unlawful Activity
Verbal Aggression