Administrative Request Referral Form

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June 16, 2025

Instructions: Please fill out this form in it's entirety. Clicking 'Submit' below will send copies of the form to the Counseling Center. Please provide the student with a copy of this form as well (a print option will be displayed after clicking 'submit').

Student Contact Information Student ID#:
First Name:
Last Name:
Email Address:

Referring Faculty/Staff Contact Information Your Name:
Your JMU Email Address:

Referral Information

The student must have his/her first assessment session at the Counseling Center no later than (mm/dd/yyyy):

Reason for referral (please specify dates and times):

Click 'Submit' below to send your request to the Counseling Center.