This form is for teaching / administrative / residential staff referring a student to the Counselling Centre.

• The form must be completed by both staff and student together. It is the responsibility of the referring staff to get the student's consent.
• The therapist will assess the student's needs and risk level. The student's attendance for sessions (with therapists and/or psychiatrist), assessed risk level, and support recommendation for faculty / departmental / residential will be communicated to the referring staff via email.
• Referring staff may contact the Counselling Centre for information on number of sessions attended, date of last attended session and risk level for a period of up to 1 year from date of referred assessment. All further counselling information beyond 1 year will be kept confidential within the Counselling Centre, except in life-threatening situations as dictated by professional ethics or unless student again provides consent.