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Counseling Referral | Bismarck State College

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Counseling Referral

Before filling out and submitting the referral form below, it can be helpful to contact the MACC to briefly speak with a mental health counselor about the reason for referral or questions about the situation.

Referrals are usually most effective when they are done with the student being referred. It is encouraged that you speak with the student about your concerns if possible. However, this is not a requirement for referring or consulting regarding a student.

For any questions or concerns, contact:
Mystic Advising and Counseling Center
Student Union, 1st Floor, Room #126
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?  

* Is it permissible for us to share with the student that you are the referring party?  

* Please select the category of the concern (select all that apply).  

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?