Athletics Counseling Center Referral Form

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This form is for Fredonia Athletics staff to provide information and referrals to the Counseling Center. This form is checked once per day by CC staff, if you have an urgent need please contact the office directly at 716-673-3424.

Referral Name:

Best way to contact you (email, office phone, cell phone):

Student Athlete's Name:

Sport:

Summary of the concern:

Please check all that apply:

I have provided the student athlete with information regarding the Counseling Center; student intends to seek services as needed.

I would like a member of the Counseling Center staff to reach out to the student athlete to coordinate care. Please note, the student should agree to have a CC staff member contact them. Please provide the student's phone number in the 'additional information' section at the bottom of this form.

I would like to coordinate care with this student athlete and have suggested they sign a Release of Information (ROI) with the Counseling Center.

I would like speak with a member of the Counseling Center staff in regards to this student athlete.

Additional Information:

Submit

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