Management Forms: An Accountable Referral Form

 

An Accountable Referral System

A model referral form that was used by the LAC at CSU Long Beach is reproduced below. It was adapted from a form used by the counseling center at Marquette University ( Milwaukee , WI ) and may be freely adapted by any institution that finds it to be useful. The form can be printed on three-part NCR  (carbonless ) paper and will provide an accountable way to refer and monitor the referral. Procedures for completion of the referral form are described below the copy of the form.

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Learning Assistance Center

 

TO:_____________________ DATE:________________

 

DEPT:___________________ ROOM_____ TELE:______

 

Please Help: ________________________ ______________

(Last Name) (First Name) (Tele) |

 

A student in the School of

( ) Education     ( ) Engineering

( ) Applied Arts & Sciences   ( ) Fine Arts

( )Business Administration   ( ) Letters & Sciences

( )Other _____________

who has requested help with_____________________________

PLEASE RETURN THE STUDENTS REFERRAL FORM TO ME WITH

YOUR COMMENTS/RECOMMENDATIONS NOTED ON THE BACK.

 

Referred by _________________

Pink (student)

Yellow(Referral) | Dept ___________Tele__________

White(File copy)

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Procedures for completion of the LAC referral form:

1. Fill in the request form completely

2. Under remarks, remember that you do not compromise the students

confidentiality. A suggested remark, when in doubt, is simply

"Please help Joe. His question seems more in your area than

mine."

3. Tell the student how the form is distributed and monitored.

4. Distribution is as follows: pink copy to the student; yellow copy through campus mail;

and white copy to LAC for filing and follow-up

5. All referrals are followed up both with the helping professional and the student

within 7 to 10 days to insure that the student was taken care of.

6. All referrals become part of the semesterly report.