Counseling Referral
Counseling Referral
Please complete this report form for any concerns about a person who has discussed or demonstrated depression, suicidal thoughts, self-harm, stress, or other areas in which the person might benefit from the free counseling service offered by Three Rivers College. Three Rivers College takes these reports seriously and will take steps to provide assistance as warranted. You may contact Dean of Student Services, amatthews@trcc.edu, to follow up or if you have questions. Please note these forms are not intended to report emergencies. In case of emergency, please call 911.
Your Information
Name
Title
Email
Phone Number
Date & Time
Place
Date Of Incident
Time
(Mandatory)
Location
Who’s Involved
(Mandatory)
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Questions
Narrative
Please provide as much detail as possible. When referring someone other than yourself, the Who's Involved section should be completed with the information of the person being referred.
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