NTU Counseling Service Referral Form

This form can be filled out by ANYONE within the NTU community. The purpose of this form is to identify students who may benefit from Navajo Technical University Counseling Services so that we may contact them. Please complete this form in its entirety and submit it immediately.

Student Information

Student Name

First

Last

T-Number

Student Phone Number

you the Behavioral

Referred By

Name

First

Last

Phone Number

Department

Does this person know that you are referring him/her to the Counseling Center?

Reason for Referral

(Please select all that apply)

Emotional Concerns

Life Concerns

Behavioral Issues

Other concerns

Once a referral is received, students will be contacted the same day or the following morning if a referral is received after hours. All information shared with the Navajo Technical University Counseling Center is confidential. After a referral is made, information regarding the student who was referred will not be shared or discussed with anyone without the student's written consent.

For questions or additional concerns, please contact the Navajo Technical University Counseling Center at 505.387.7473.

NTU Counseling Service Referral Form

Student Information

Referred By

Reason for Referral

Academics

Students

Faculty & Staff

Contact