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 ͼ 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 ͼ 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 ͼ 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. I, _________________________________have read the paragraph above and I give the referring source and the staff of the ͼ Self-Development, Counseling, and Special Accommodations Center permission to communicate regarding my follow-through on this referral. ____________________________ _______ ____________________________ ______ Signature of Student Date Signature of Referral Source Date **Note: A student should only sign this form when willing to give permission for the referring source to know about the follow-through with the referral.  0BLhq  W a b c  ! h i ÷}vrmvrbhh&VCJaJ h&V\h&V h @h&Vh @h&V5\h&VCJ\aJh @h&VCJ\aJh&V5CJ\aJh&VCJaJh @h&V\h&V5>*CJ\aJh&VOJQJ\^Jh&V5OJQJ\^JhM`}OJQJ^Jh&VOJQJ^J h J5CJ OJQJ\^JaJ  0pqb c  f g h i xyUVZ &d P gd&Vgd&Vd7$8$H$gd&V$d7$8$H$a$gd&Vi $ 6 @ \ e  >  " >PZv wySTUV 峥|qqqqqh6*h&VCJaJh&VCJaJh&V5CJ\aJh&V5CJ\aJh+5CJ\aJhh&V5CJ\aJh&VCJaJh+CJaJhh&V6CJaJhh&V56CJaJhry\CJaJhh&VCJaJhh&V5>*CJ\aJ,Zgd&VJjh&VCJaJh&V5CJaJh6*h&V5CJaJh&VCJaJh6*h&VCJaJ21h:p&V/ =!"#$% w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666866666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p(8HX`~8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666 OJPJQJ_HmH nH sH tH J`J 7}Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR Table Normal4 l4a (k ( No List bob @Default 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] i  Z 8@0(  B S  ?  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