Student-Athlete Online Referral Form

Student-Athlete Name:*

First Last

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Contact Information

Student-Athlete Email:*

Student-Athlete Cell Phone:*

Student-Athlete's Sport:*

Hidden

Sport

Referring Staff Member Name:*

First Last

Referring Contact Phone Number:*

Referring Contact Email:*

Have you expressed your concern to the student-athlete?*

Yes
No

If you are concerned that the athlete will harm themselves or someone else please activate MH-EAP immediately. If the situation is deemed unsafe call 9-1-1. If unsure if imminent risk of harm to self or other is present, please reach out to MH&P Clinic Phone 706-224-7941 or Dr. Dylan Firsick at 706-714-7208.

Please explain todays concern, with as much detail as possible:*

Are you aware of any previous history that could assist with the athlete’s evaluation?*

*Required information

MENTAL HEALTH & PERFORMANCE referral form