Central State University 1887, registered trademark

Central State University
Counseling Services
Exit From Services Form

Instructions: Faculty and staff using this form should consider all referrals as confidential. Complete the information requested and submit the form to Counseling Services in the Student Health Center. Thank you.

Please also complete the Student Satisfaction Survey located on Counseling Services Website

Counseling Services Telephone Numbers: Office: 937-376-6338 - Fax: 937-376-6048

Information

Date

Gender

Student Classification

Freshman

Yes No

Sophomore

Yes No

Junior

Yes No

Senior

Yes No

Have you participated in any of the following listed Services by Counseling Services? Please choose all that apply:

Individual or Group Counseling

Yes No

Support Groups

Yes No

Training or Workshops

Yes No

Faculty or Staff Consultation

Yes No

Study Resource Room

Yes No

Relaxation Room

Yes No

Other

Description

We notice you have discontinued receiving services. Please indicate why you have not returned.

Please provide additional comments or suggestions:

Your Email:


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