Referral For Counseling

This form can be used by students, faculty or staff to refer students for counseling.

Referrals are forwarded to: counselingcenter@csu.edu and shall receive a response within 48 hours. If a student is in crisis, please contact campus police at (773) 995-2111.

If you see this don't fill out this input box.

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

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