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COUNSELING REFERRAL FORM

Priority
Low (schedule when available)
High (schedule asap)
Emergency (see now)
Student Lives:
ABU Dorms
Grandparents
Parents/Guardian
Other Relatives
Spouse
Unsure
Apartment
Referred by
Teacher
Parent
Self
Other
Reason(s) for Referral/Problems/Concerns Related to: (please check all that apply)

Did the student's behavior necessitate contacting authorities, if so, which of the following were contacted?

Actions taken by the person referring this student

If there are supporting documents or any other items necessary, please email those to Dr. Brady Blevins at bblevins@abu.edu

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