Counseling Referral


Please use this form to refer a student to the Mystic Advising and Counseling Center.

* Student's First Name

* Student's Last Name

Student ID

* Your Name (Referral Source)

* Relationship to Student

* Your Contact Information

* Is the student aware that you are making a referral?
Yes No
* Is it permissible for us to share with the student that you are the referring party?
Yes No
* Please select the category of the concern (select all that apply).
Anxiety Depression Grief/Loss Self-Harm Academics Financial Concern Interpersonal/Relational Suicidal Ideation Other
If "other", please give a brief explanation for the reason for this referral.

Please describe the reason for referral in more detail.

What steps have already been taken to address this concern?

Counseling Referral | Bismarck State College