Office of Student AffairsWellness and Counselling Centre Referral Form for Psychological Counselling Service (CONFIDENTIAL)

Office of Student Affairs
Wellness and Counselling Centre
Referral Form for Psychological Counselling Service (CONFIDENTIAL)

Registered full-time undergraduate and postgraduate students are eligible for counselling service.

* Required field

Part 1. Referrer Information
Salutation: *

Salutation: Prof. Dr. Mr. Ms. Mrs.
Full Name: *
Post: *
Affiliated Unit: *

Affiliated Unit: College Faculty/Academic department Professional and administrative services unit Other unit (please specify) Other unit (please specify)
College:
Faculty:

Faculty: Arts Business Administration Education Engineering Law Medicine Science Social Science
Academic Department:
Professional and administrative services unit:
Contact Tel.: *
Must be 8 digits. Currently Entered: 0 digits.
Email: *
Alternative contact person (Name):
Alternative contact person (Contact Tel.):
Must be 8 digits. Currently Entered: 0 digits.
Alternative contact person (Email):
Part 2. Student Information
Full Name of Student (English): *
Student I.D.: *
Must be 10 digits. Currently Entered: 0 digits.
Contact Tel.: *
Must be 8 digits. Currently Entered: 0 digits.
College/Graduate School: *
Faculty: *

Faculty: Arts Business Administration Education Engineering Law Medicine Science Social Science Inter-faculty or other
Academic Department: *
Programme: *

Programme: Undergraduate Research postgraduate Taught postgraduate
Year of Study: *

Year of Study: Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Other (please specify) Other (please specify)
Problem(s)/Reason(s) for Referral: *

Problem(s)/Reason(s) for Referral: 1. Study difficulties 2. Absent from classes 3. Emotional disturbances 4. Behavioural abnormalities 5. Interpersonal relationship problems 6. Other
Please provide details for the above selected item(s):
Time since the problem(s) has (have) occurred: *

Time since the problem(s) has (have) occurred: <1 month <3 months >3 months
Student's motivation to seek help: *

Student's motivation to seek help: Low Adequate High
Has the student been informed of this referral for psychological counselling service? *

Has the student been informed of this referral for psychological counselling service? Yes No
Other comments/information:
Are you the Level I or II Academic Advisor for the student?

Are you the Level I or II Academic Advisor for the student? Yes No
Part 3. Collaborative Case Management with Academic Advisors
Would you consider communicating with the student’s case counsellor for collaborative case management (If yes, please obtain the student's consent and upload the signed form below)?

Would you consider communicating with the student’s case counsellor for collaborative case management (If yes, please obtain the student's consent and upload the signed form below)? Yes Not required at the moment
Please download the Student Consent Form here:
Consent Form
Please upload the signed form here:

Attach Files
Disclaimer The personal data collected will be used by WACC, OSA and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.

Office of Student AffairsWellness and Counselling Centre Referral Form for Psychological Counselling Service (CONFIDENTIAL)

Part 1. Referrer Information

Part 2. Student Information

Part 3. Collaborative Case Management with Academic Advisors

Office of Student Affairs
Wellness and Counselling Centre
Referral Form for Psychological Counselling Service (CONFIDENTIAL)