Refer a Student

Thank you for taking the step to connect a student to support. Currently, our Therapists are providing services both in person and via Zoom for Healthcare. DMHCS services are only available to students who are currently enrolled in courses. Please note: For meetings via Zoom, students must be located in the state of New York at the time of your appointment. We will be following up with this student shortly, and will be providing them with appropriate resources and options for support moving forward.

DISCLAIMER: This form is not for emergency response or crisis intervention. If you have concerns about a student’s immediate health or safety, please contact emergency services right away. (911 or 914-606-6911 for on campus emergencies)

This form is for use by WCC faculty and staff only.
The Department of Mental Health and Counseling Services will assess referral form and reach out to student within 24-48 business hours.
DMHCS Therapists will not contact you unless they have questions or require additional information.

Your Information

Your Name *

Your Email Address *

Your Phone Number

Position at WCC *

Relationship to Student you are referring *

Student's Information

Students Legal Name *

Students Preferred Name

Student ID# *

Student's WCC E-mail Address *

Student's Phone#

Student's Additional Optional Email Address

Is this student currently enrolled in courses at Westchester Community College? *

(select all that apply)

Yes

Unsure

Is this student taking classes on campus this semester? *

Yes

Unsure

Reason for Referral

Please explain your reason for referring the above student to the Department of Mental Health and Counseling Services. *

(*Include observations, statements made, and specific concerns)

How long have you observed these behaviors/warning signs? *

One Time

1-2 weeks

2-4 weeks

5+ weeks

Have you informed this student that you are referring them to the Department of Mental Health and Counseling Services? *

Yes

If NO to the above question, please explain your reason for not informing the student of your referral

*The Department of Mental Health and Counseling Services encourages our community members to inform students if they are referring them to our department. If you have any questions about this and/or would like tips on how to talk to a student of concern, please reach out. We are here to help!

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Please read the following statements before submitting

This form is for use by WCC faculty and staff only.
The Department of Mental Health and Counseling Services will assess referral form and reach out to student within 24-48 business hours.
The Department of Mental Health and Counseling Services will not contact you unless they have questions or require additional information.
This form is not for students in crisis or in need of immediate mental health support. If you believe the safety of a student or community member is at risk, please dial 911 or contact WCC security at 914-606-6911.

Acknowledgement *

I have read the above statements and understand the Department of Mental Health and Counseling Services referral process.

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Westchester Community College, State University of New York

Refer a Student

Your Information

Student's Information

Reason for Referral

Contact Information

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