Referral Form (Faculty & Staff)

This form may be used to share your concern about a student and to refer a student to Counseling Services. Please send the completed form in a sealed envelope to: Scott W. Radtke, Associate Dean of Students for Health and Wellness, Counseling Services, SPC 3.

Faculty Referral form.pdf

Print this form and send it to Counseling Services, SPC 3.

For counseling staff members to receive information about students does not require students’ knowledge or permission. According to law and professional ethics, for counseling staff members to disclose any information about students (including whether they are clients) does require students’ knowledge and written permission. Students have the right to withhold permission for release of information or only give permission for the release of selected information about their situation.

Helping Students in Distress

This information is provided to assist you in becoming aware of signs of a distressed student, things that you might do to help the student, indicators of possible suicidal ideation, and when and how to make effective referrals for additional help.

Tips for Recognizing Troubled Students

At one time or another, everyone feels depressed or upset. However, there are three levels of student distress which, when present over a period of time, suggest that the problems are more than the “normal” ones.

Level 1 Level 2 Level 3
Although not disruptive to others in your class or elsewhere, these behaviors may indicate that something is wrong and that help may be needed These behaviors may indicate significant emotional distress or either reluctance or inability to acknowledge a need for personal help These behaviors may usually show that the student is in crisis and needs emergency care
Serious grade problems Repeated request for special consideration Highly disruptive behavior (hostility, aggression, etc.)
Unaccountable change from good to poor performance New or regularly occurring behavior which pushes the limits and/or may be disruptive to the class Inability to communicate clearly (garbled, slurred speech, disjointed thoughts)
Change from frequent attendance to excessive absences Unusual or exaggerated emotional response Loss of contact with reality (seeing/hearing things that are not there, beliefs or actions at odds with reality)
Change in pattern of interaction   Overt expressions of current suicidal thoughts or plans
Marked change in mood, motor activity, or speech   Homicidal threats
Marked deterioration in physical appearance    

What You Can Do To Help

Responses to Level 1 or Level 2 Behavior Responses to Level 3 Behavior
Talk to the student in private when you both have time Stay calm
Express your concern in non-judgmental terms Make emergency referral as listed below
Listen to the student and repeat the gist of what the student is saying  
Respect the student’s value system  
Ask if the student is considering suicide  
Make appropriate referrals if necessary  
Try to make sure the student understands what action is necessary  

When to Make a Referral

Even though a student asks you for help with a problem and you are willing to help, there are circumstances when you should suggest additional resources:

  • You are not comfortable in handling the situation.
  • Personality differences might interfere with your ability to help.
  • You know the student personally (friend, neighbor, friend of a friend) and think you may not be objective enough to help.
  • The student is reluctant to discuss the situation with you.
  • You feel little progress in dealing with the student about these issues over time.
  • You feel overwhelmed or are pressed for time.

How to Make a Referral

To the student:

  • Be frank with the student about the limits of your time, ability, expertise, and/or objectivity.
  • Let the student know that you care and think s/he should get assistance from another source.
  • Assure her/him that many students seek help during college.
  • Try to help the student understand what to expect if s/he follows through on the referral.

Consider these questions before making the referral:

  • What are the appropriate and available resources for the student?
  • With whom is the student likely to feel most comfortable?
  • Who will make the initial contact, you or the student?

Consultation is Available

If you have concerns about a student, counselors at Counseling Services are available for consultation. Some of the ways we might help include:

  • Assessing the seriousness of the situation
  • Suggesting potential resources
  • Determining the best way to make a referral
  • Helping you clarify your own feelings about the student and the situation

Counseling Services

Any currently enrolled student may use the services. Students are encouraged to make their own appointments if possible. There may be a wait of a few days before seeing a counselor for a scheduled appointment. In emergency situations we will assist any student immediately. Be sure to tell the person scheduling the appointment that the situation is an emergency. At the student’s first visit s/he will fill out information and consent forms prior to meeting with the counselor. During the first appointment, the counselor will begin to assess the student’s needs and determine the most effective way of helping.

In an Emergency

Try to stay calm. Find someone to stay with the student while calls are made.

For students expressing a direct threat to themselves or others, or who act in a disruptive, bizarre, or a highly irrational way, call:

  • 9-911 on your office phone (or 911 on a local cell phone) if you feel anyone poses an imminent threat to self or others
  • Counseling Services (8 a.m.–4:30 p.m. Monday–Friday) 6574 on your office phone (or 920-832-6574 on a local cell phone), for immediate consultation. Evenings and weekends you may call 920-419-8167 to speak to the counselor on duty

For students who exhibit severe anxiety, depression, suicidal thoughts, or any other intense emotional disturbance, but for whom no immediate harm appears likely, please call:

  • Counseling Services (8 a.m.–4:30 p.m. Monday–Friday) 6574 (or 920-832-6574) for consultation and referral

Do’s and Don’ts in Responding to Suicidality

  • DO show that you take the student’s feelings seriously.
  • DO let the student know that you want to help.
  • DO listen attentively and empathize.
  • DO reassure that with help (s)he will recover.
  • DO stay close until help is available or risk has passed.
  • DON’T try to shock or challenge the student.
  • DON’T analyze the student’s motives.
  • DON’T become argumentative.
  • DON’T react with shock or disdain at the student’s thoughts and feelings.
  • DON’T minimize the student’s distress.

Adapted from Central Michigan University’s web page.

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