Student referral form

Please complete form electronically. To print, hit the 'view' button at the bottom of the page then fax to the appropriate office/department.

*Indicates required field.
 

Student information

First name*
Last name*
UBC student number*
Birth date*
mm/dd/yyyy format
Telephone* () -
Date*
mm/dd/yyyy format
 

Referred by

Office/department*
Telephone* () -
Name of faculty/staff member*
 

Referred to

Name of faculty/staff member (if applicable)
Service* Counselling Services
Fax: 604.822.4957 Tel: 604.822.3811
Student Health Service
Fax: 604.822.7889 Tel: 604.822.7011
 

Purpose of referral

Purpose* Advising
Advocacy/complaint handling
Medical assessment/treatment
Counselling
Group/workshop/program (please specify)
Emergency/urgent* Same day     Within 5 days
Return communication is requested* Yes     No
Continued services being provided by referring unit* Yes     No     To be determined
 

Relevant information

 

Consent to release information

I hereby authorized the release of information regarding*
I understand that the information shared is restricted to personnel in the following offices/departments*
Counselling Services     
Student Health Service     
Other (please specify)
The purpose of this information is*
This release expires in 12 months, unless another date is specified.

mm/dd/yyyy format
 
 

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