Rapid Referral Form

Florida Memorial University > Student Engagement > University Counseling Services > Rapid Referral Form

University Counseling Services (UCS) is dedicated to providing the FMU community with clinical counseling services, supportive intervention, and referrals to facilitate wellness, personal growth, and success. Please contact the UCS at 305-626-3138.

Rapid Referral Form
Questions marked by * are required.
1. Date: *
2. Student Name and Student ID#: *
3. Student Address or Location: *
4. Student Cell Phone or Contact Number: *
5. Student Email: *
6. Referral Source Name, Phone, and Email: *
7. Reasons for Referral: *

  • Anxiety/Worry
  • Conflict Resolution
  • College Adjustment
  • Low Academic Performance
  • Weight/Eating Disorder
  • Sleep Disturbance
  • Social Skills
  • Stress Management
  • Time Management
  • Trauma/Crisis
  • Grief/Loss
  • Mood Disorder
  • Behavioral Issues
  • Unusual/Psychotic Behavior
  • Anger Management
  • Depression
  • Roommate Issues
  • Self-Esteem
  • Alcohol/Substance Use/Abuse
  • Relationship/Interpersonal Issues
  • Evaluation
  • Other
8. Please Provide additional information or recommended action: