Alabama State University Counseling Center Referral Form

To be referred for University-based services, a student must be currently enrolled.

Reason for Referral:

Difficulty making transition:
Social problems:
Achievement problems:
Major psychosocial or mental health concern:

Current school functioning and desire for assistance:

Absent from school:
Overall academic performance:
Information about service
An appointment to initiate help
Someone to contact them to offer help

Follow-Up Confirmation:


Please complete this form electronically and/or print it. Submit it to the University Counseling Center if on-site. If off-site, email to, or fax to (334)334-229-6116.