COUNSELING & WELLNESS

St. Joseph Student Academic and Health Center
Suite 202
504-520-7315
counseling@xula.edu

Student Referral Form

REFERRAL TO:	DATE:
STUDENT NAME:	XULA ID:
EMAIL:
STUDENT ADDRESS:	APT. #
ZIP CODE:
CLASSIFICATION:	MAJOR:
TYPE OF REFERRAL:
ACADEMIC PERSONAL TESTING SOCIAL OTHER
REFERRED BY:	TITLE:
DEPARTMENT:	CAMPUS PHONES:
REASON FOR REFERRAL:
WAS THE STUDENT INFORMED OF THIS REFERRAL? Yes No