By Melanie Sims,2014-12-25 01:44
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    Counseling and Psychological Services

Form should be directed to:

    ? Russ Federman, Director

    ? Lenny Carter, Assistant Director, Clinical Coordinator

    ? Rick Heisterman, Consultation Services Coordinator

    ? Daytime On-call Clinician

    ? Other CAPS Clinician

     Name: __________________________________________

Form being sent via:

    ? E-mail Attachment

    ? UVa Messenger Mail

    ? Fax

CAPS Fax #: 243-6693

    Referral to Counseling and Psychological Services

Date of Referral: ___________________________________

Student Information

    Student’s Name: ______________________________________ ID#: ___________________________________ Student’s Residence Phone: _____________________________ Cell: ___________________________________ E-mail: ___________________________ Residence Location: ____ On Grounds ____ Off-Grounds

Referring Office Information

    Name of Referring Professional:__________________________________________________________________ Office Phone: ___________________________________ E-Mail: ____________________________________ Office/Dept.: ____ ODOS ____ Res Life ____ Office of VPSA

     ____ Academic Dean / School: __________________________________________________________________ Other: ______________________________________________________________________________________

Reason for Referral:

    (multiple categories may be checked)

    ____ Student requests help for psychological distress ____ Professional perceives student need for help ____ Request for assessment of psychological issues pertaining to poor academic performance ____ Professional concerned about student’s safety requests risk assessment and recommendations

    ____ Student has been disruptive and/or has raised concerns of other students ____ Substance abuse assessment

    ____ Conduct code violation ____ Honor code violation.

    Referral for: ____ assessment and recommendations, ____ follow-up tx and/or case management ____ ODOS Interim suspension request for assessment and recommendation

    ____ Post-hospitalization request for recommendation re: return to university housing ____ Recommendation to ISO for student study abroad

    Other referral issues and/or comments about above items: _____________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Requested Response from CAPS

    (multiple categories may be checked)

    ____ CAPS response to referring individual not requested

    ____ Request referring professional notified when student initially seen at CAPS

     (no additional feedback about session expected)

    ____ Request verbal communication about student’s status/condition with referring professional following contact

     with student

    ____ Request written communication about student’s status/condition with referring professional following contact

     with student

     Type of communication: ____ E-mail ____ Hard copy letter/report

    ____ Request on-going communication about student’s status/condition as-needed with referring professional

    Other requested response or comments about above items: _____________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    Release for Verification of Attendance

____ No release obtained - CAPS response not requested

    ____ Release obtained for verification of attendance (below).

    I hereby authorize CAPS to inform referring professional as to whether or not I attended an initial appointment. This release does not cover the content of anything discussed with CAPS professionals nor does it pertain to any contact beyond my initial CAPS session. If the referring individual is requesting verbal or written feedback from CAPS, I understand I will be given the option of signing a separate release at the time of my appointment at CAPS.

    ________________________________ /_________________________ _______________________

     Student Signature / Student ID # Date

    I authorize verification of attendance via e-mail communication. I further understand that e-mail is not a secure means of communication and UVa. Counseling and Psychological Services cannot guarantee that the above-identified information won’t be accessed or read by individuals other than the named recipient.

    _________________________________________ ___________________________

     Student Signature Date

    _________________________________________ ___________________________

     Witness Date

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