        Historically American.  Uniquely Caribbean.  Globally Interactive. 
 
Office of Counseling & Placement 
#2 John Brewer’s Bay ● St. Thomas, U. S. Virgin Islands 00802 ● Tel:  (340) 693-1134 ● Fax:  (340) 693-1091 
RR1 Box 10000  ● St. Croix, U. S. Virgin Islands 00850 ● Tel:  (340) 692-4187 ● Fax:  (340) 692-4008 
Website:  http://www.uvi.edu 
 
 
COUNSELING REFERRAL FORM 
 
Directions:  Please give one copy to the student and keep one for your file before faxing, emailing, or 
interoffice mailing this form. 
 
Name of Student:  __________________________________________________________ 
Classification:      
  Freshman 
  Sophomore 
  Junior 
  Senior 
Student ID Number: _________________________ 
Major:  ______________________________ 
Phone Number:  ______________________________ 
Email Address:  ______________________________ 
 
Nature of Referral:  Please check the area(s) for which the student is being referred.  Provide as much 
information as possible concerning the student’s situation and reason for referral.   
  Academic Counseling 
  Career Guidance 
  Employment Needs 
  Personal Counseling 
  Judicial Requirement 
  LAP 
  Other (Please specify):  ____________________________________________________________ 
 
Comments: 
 
 
 
 
 
 
 
 
 
For Counseling Office Use Only 
Follow-Up Action: 
 
 
 
 
 
 
 
 
 
 
 
Referred by 
 
 
 
 
                   Phone #  
 
 
Date