Referral Form

Referrer Information

Referral General Information

How long has he/she been attending current university?

Name of Educational Institution

Key professional contact

The student is aware of the referral

Yes No

Please give as much information as possible about the concern including onset, severity, duration, and the reason for referral now.

Has the person been already included in any kind of SEN or other programs at previous level of education?

Yes No

Is he/she included in any kind of SEN program at the present level of education (university)?
If yes, please share the duration and outcomes.

Is family aware of the student’s current referral?

Yes No

Are there any risks of harm?

Yes No

If so, kindly indicate university policy and steps taken to ensure safety?

To Self

Background Information

Previous hospitalization related to mental health difficulties?

Yes No

If yes then please give us some details: When? Where? For what reason?

Previous mental health treatments?

Yes No

If yes then please give us some details: When? Where? For what reason?

If yes, please provide the dates, recommendations and action plans integrated both in previous schools and at home

Informed Consent from the Student

I agree to information being shared between the counsellor and Flourishing Minds Clinic

Yes No

Any of the information taken by the university psychologist will be kept confidential and always secured by the therapist and shall not disclose it to anyone without any prior written consent by the client/patient. In case you have any questions regarding confidentiality, please discuss this with the university psychologist (contact number.............; contact email...................).

Informed Consent from the University Counsellor

I agree to information being shared between agencies to help my student.

Yes No

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Referrer Information

Referral General Information

Current Concerns

Background Information

Informed Consent from the Student

Informed Consent from the University Counsellor

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