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Counseling Services- Referral Form


This is a non-emergency form. 

If you believe the student being referred poses a threat of harm to self or others, please contact the Security Office based on your campus, dial 9-1-1, or connect with Baycare. Otherwise, please proceed with the form.

Welcome to the Counseling Services Referral!

Faculty, staff, and parents play a vital role in supporting college students through their academic journey. Valencia Counseling Services, offers private educational counseling tailored to meet the unique needs of our students. From short-term interventions to academic strategies for success, we are all about helping students succeed. By referrring students to our services, you are helping them access the support they need to thrive. Thank you for partnering with us in promoting the well-being and success of our students!

Please Note: 

  • Allow 24-48 business hours for a counselor to reach out to the student regarding this concern.
  • This form is not reviewed after hours, over the weekend, or during college holidays/breaks/closures.  All forms will be reviewed upon reopening of services. Please review the College's Important Dates & Deadlines for college closure and holidays. 

Are you a student trying to connect with a counselor? Visit the Counseling Services website to connect by selecting the "Talk to a Counselor" option. 

Background Information

 
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Faculty; Staff; Administration; Parent; Student; Community Member
Email address must be of a valid format.
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Select One
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mm/dd/yyyy
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Student of Concern

Involved party 1

Information Regarding Concern

What are the student's specific needs/concerns? Select all that apply.(Required)
You must make at least one selection.
This field is required.
Is the student aware that they are being referred to Counseling Services?(Required)
You must make at least one selection.
While we do our best to keep Counseling Referrals private, at times it is necessary to identify the reporting party. If necessary, may we share your name with the student?(Required)
You must make at least one selection.
I understand that referrals from this form will be received during normal business hours (M-F, 8AM - 5 PM) and are not monitored after hours, on weekends, or during official College holidays. Please contact campus security if there is an immediate risk of harm to self or others prior to submitting this form.(Required)
You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission