JFK School of Psychology at National University has partnered with your school/agency to provide therapeutic, strength-based counseling support. In order to receive services, please complete this Request/Referral Form.  Counseling is confidential, as is this form.

If you are a student at one of our partnering schools/colleges, you are eligible to request services through our Community-Based Counseling Profgram. Inforrmation discussed in treatment will not become part of your student record. Counseling through this program is typically brief, aimed at helping clients achieve reachable goals within an 8-12 week/session timeframe.

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Please note this program is not able to provide crisis counseling.  Your referral may be placed on a waitlist and our counselors will reach out to you (the potential client) as soon as they are able to.

If you (or the individual being referred) are in need of immediate support, are in crisis, and/or are currently experiencing life threatening danger, please do not complete this form. Instead, please call:

The National Suicide Prevention Lifeline (Crisis Line) (1-800-273-8255)
The National Crisis Textline (text the word HOME to the number 741741)
9-11
Or go to the nearest emergency room.

If you are a student at one of our partnering schools/colleges, and you are currently on campus, you can speak with an academic counselor, instructor, or Administrative staff who can also assist you in finding support.

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If you (or the person referred) are not in need of crisis support, please click "Next" to continue.  You will be asked a series of questions to help us identify a counselor who would be a good fit for you (the potential client). 

* Denotes required field

If you selected "No" to the above question, "...has the Potential Client been notified about this referral?", please do not complete this form until you have spoken with the individual you are referring for service.  We will only take referrals for Potential Clients who know they are being referred and are willing to participate. 

* Denotes required field 

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+Please note that this service is not specialized in the treatment of addiction.  If you identify "substance use/abuse" as the primary concern and need specialized treatment for addiction, please consult a physician for appropriate referrals. 

++Past crisis or trauma refers to prior experiences that the PC may still be struggling with but do NOT pose imminent risk of harm or safety to them or others. If you choose this item, please provide a brief narrative in the space below for the past crisis or trauma indicated.

+++Choose this item ONLY when current/ongoing crisis or trauma does NOT pose imminent risk of harm or safety to the Potential Client or others. If you choose this item, please provide a brief narrative in the space below for the current/ongoing crisis or trauma indicated 

Please be reminded that this service does NOT offer crisis counseling.  If the individual being referred is in need of immediate support for a major crisis and/or a life threatening danger, do NOT proceed with this referral.  Instead, seek immediate assistance from the emergency resources listed at the beginning of the form.

* Denotes required field 

Preference for Service and Availability: 

Depending on your site, you may have the option to choose between telehealth and in-person services at this time.

If that is the case for you, please indicate your preference for service below. We will try our best to offer services in accordance to your preference but cannot guarantee your preferred service will be available.

If your site only offers in-person services at this time, please check "In-Person" below.

Regardless of telehealth or in-person service, please also indicate your availability below.

Once you click "Submit," this referral will be sent to the National University, JFK School of Psychology Community-Based Counseling Program (CBCP) Referral Team, to be reviewed and processed in a confidential manner.  A counselor from CBCP will reach out to you or the person you are referring as soon as an availability opens up to render services.  Please be advised that wait times could be up to 3-4 weeks.  If you or the person you are referring is in need of more immediate assistance, emergency resources are listed at the top of this form.