Initial Referral Information/Basic Assessment Form
Department of Mental Wellbeing
Email this form to bfranklin@rio.edu when completed Full Name:____________________________________Date of Birth: ______________Email______________________ Address: ________________________________________________________________________________________ _______________________________________________________________________________________________ Commute/Campus: ____________________________ Phone Number:______________________________________ Student Id: ______________________________ Preferred Gender:_______________ Race:______________________ Major: _______________________________________ Sports/Activities:_____________________________________ SYSTEM INVOLVEMENT ■ Child Welfare
■ Juvenile Justice
■ Mental Health
■ Drug & Alcohol
Presenting Problem:
OUTCOME- TO BE COMPLETED BY DEPARTMENT OF MENTAL HEALTH PROFESSIONAL ■ Referral
■ Intake
Notes/Information:
PO Box 500 • Rio Grande, Ohio 45674 • rio.edu
Initial Referral Information/Basic Assessment Form • 9-6-2022 JA