Make a Referral

If you are concerned about a student’s mental health and well-being, you can make a referral to Student Mental Health Services. Fill out the referral form (preferably with the student) below and we will contact the student within one business day to make an appointment.

Student Knowledge of Referral

Student Knowledge of Referral Student is aware of referral The referral has been discussed in detail with the student

Note: Students should be aware of this referral and agreeable to their information being shared with Student Mental Health Services
Student full name Student full name First Last
Student ID number
Must be 9 digits. Currently Entered: 0 digits.
Student email (ontariotechu.net)
Phone Phone - ### - ### ####
Preferred method for session:

Preferred method for session: Secure telephone or video appointment In-person appointment
Referral source information
Name Name First Last
Email
Job title
Department/faculty
Date of referral: Date of referral: / MM / DD YYYY
Identified needs and concerns
Current risk factors:

Current risk factors: Suicide risk Academic concerns Culture shock Disordered eating/body image Family / relationships Hopelessness / sadness Isolation Self-esteem Self harm Sexuality Stress / anxiety Substance misuse Test anxiety Other Other
Priority

Priority Low (schedule when available) High (schedule as soon as possible)
Proposed/desired response
Personal information is collected under the authority of the University of Ontario Institute of Technology Act (2002), and will be kept confidential following the guidelines set forth by FIPPA and PHIPPA.

Make a Referral

Make a Referral

Referral source information