Grief Outreach Initiative (GOI) Referral Form

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Thank you for reaching out to the Grief Outreach Initiative at UTK and for entrusting your student to us. We will take utmost care to ensure they receive the support they need during this time. As a gentle reminder, the GOI exists to fill a gap in a student's life, when they are troubled enough by loss (death or nondeath) to need help but not necessarily in need of long-term services. GOI mentors provide support, friendship, and a listening ear, but not professional counseling. In this way, we can be a help to school counselors and school social workers, freeing up some space for students who especially need services from them to get them. We are at our best with students who, for a brief time, need a grownup who "gets it!"

Please fill out the required information below so that we can keep in contact with you and match your students with a mentor. If you have any questions, please email me at sander96@vols.utk.edu, or call me at 931-267-0451.

Upon completing this form, you will receive an email receipt. This receipt will include a link to edit your response, so you can return to complete or fix the form, or to attach the consent form if you receive it after the referral is made.

Take care & be well,

Beth Anderson Walker, MA, LPC-MHSP (TN), NCC

GOI Doctoral Coordinator

Email *

Today's Date

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Your name *

Please enter the best phone number to reach you: *

Student's school *

Student's name *

Student's age *

Student's grade *

Please provide a brief description of the reason for referral *

If you are referring multiple students, please provide a priority level for each student

Please check the appropriate box if you are referring siblings:

I would like this student and their sibling paired together

I would like the student to have a different mentor from their sibling

I think the student will do well either alone or paired with their sibling.

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Please note: we cannot consider a referral complete until a signed consent form is received. Please send completed, signed consent forms to lwheat@utk.edu.

A copy of your responses will be emailed to the address you provided.

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