COUNSELING & WELLNESS

Building 15
Located between St. Joseph and St. Katharine Drexel Resident Halls
504-520-7315

Student Referral Form

REFERRAL TO:	DATE:
STUDENT NAME:	XULA ID:
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