Referral Form

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Referral Form

Welcome! Thank you for choosing the University of Saint Joseph Counseling Service.

Service Hour
- All sessions are run by appointments
- Services are not available on Saturday, Sunday and Public Holidays

Venue: Counselling Room, 1st Floor, Ilha Verde Campus
Email: counselling@usj.edu.mo
Tel: 85925693

Email *

Referred by (Your Name) *

Relation to person receiving referral *

Referral source contact detail (Your Email, Phone) *

Service Required *

Consultation (I hope to learn how to be a good companion of this person)

Counselling (This person is consent to be contacted by the counsellor)

Group support

Is the person acknowledge of referral? *

YES, the person is aware and accept the referral

AMBIVALENT, has been discussed with the person but s/he is in doubt

NO, has not been discussed with the person

Name of person receiving referral *

Gender of person receiving referral *

Female

Male

Type *

Student

Staff

External Client

Email/ Contact No. of person receiving referral

Reason of Referral/ Problems of Concern *

Suicidal and/or Self-harm Behavior

Mental Health Crisis and related issue

Changes in academic performance (e.g., Serious drop in grade and infrequent class attendance)

Changes in moods (e.g. tearfulness, nervousness, agitation)

Behavioral Disturbance (e.g., dependency, aggressiveness )

Interpersonal Relationship Difficulties

Self-Esteem Issue

Family Issue

Stress Management and Copings

Substance use and Addiction

Other:

Required

On a scale of 1-10, please identify how serious (immediate) this problem is: *

Less Serious

Very Serious

Special needs to consider and/or risks identified about this person receiving referral *

What are the times available?

Mon

Tue

Wed

Thurs

Fri

Language of Preference

Cantonese

English

Mandarin

Portuguese

Clear selection

~ Thank you for taking the time to complete this form ~

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