Counseling Referral Form

Counseling Referral Form
If you or an MPCC student you know has expressed an interest in seeing an MPCC Counselor, please complete this form. Please remember, counseling sessions are voluntary. Our counselors will follow-up on a referral if you or the referred student does not contact the counselor within one week.
Referrer's Name:

First Name Last Name
Referrer's E-mail Address: *
example@example.com
Student's Location: *

Broken Bow Imperial McCook North Platte Ogalalla Valentine
Name of Student Being Referred:

First Name Last Name
Student's Phone Number: *

Area Code Phone Number
Student's E-mail Address: *
Please Explain Reason for Referral : *

0/500
Enter the message as it's shown *
If you have any questions or would like immediate assistance,
contact Brian Obert at obertb@mpcc.edu.
Should be Empty: