Student Referral Form - Kilgore College

Student's Name(Required)

First Last

Student's Email

Enter Email Confirm Email

Student's Preferred Phone Number(Required)

Your Name(Required)

First Last

Your Student Id

If applicable. You don't need to be a student to refer someone.

Your Email

Your Department

I informed the student that I would be making a referral to Counseling?

Yes

A counselor may contact you to get more information about your reasons for referring the student. Your availability Monday-Friday, 9-5, to be contacted by a counselor regarding this student?

Your Phone

Reason for Referral(Required)

If you are concerned about a student’s immediate safety, please call 911

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