MENTAL HEALTH & PERFORMANCE referral form Student-Athlete Name:* First Last HiddenContact Information Student-Athlete Email:* Student-Athlete Cell Phone:*Student-Athlete's Sport:*BaseballMen's BasketballWomen's BasketballEquestrianFootballMen's GolfWomen's GolfGymnasticsSoccerSoftballMen's Swimming & DivingWomen's Swimming & DivingMen's TennisWomen's TennisMen's Track & Field / XCWomen's Track & Field / XCVolleyballCheer/DanceHiddenSport 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 Δ