Counselor Referral Request

(All files are held in strict confidence)




Local Address

Permanent Address

  xxxxx-xxxx
  xxxxx-xxxx
  xxx-xxx-xxxx
  xxx-xxx-xxxx


Availability: To assist us in meeting your scheduling needs, please check the box in ALL time slots that you are available to meet with a counselor.
8:00 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 5:00
Mon
Tue
Wed
Thu
Fri
Primary concern(s): (check all that apply)
Abuse - Physical, sexual, emotional, neglect Gambling Perfectionism
Aggression, violence Greiving, mourning, deaths, losses, divorce Pessimism
Alcohol use Guilt Procrastination, work inhibitions
Anger, hostility, arguing, irritability Headaches, other kinds of pains Relationship problems (with friends, relatives, at work)
Anxiety, nervousness Health, illness, medical concerns, physical problems School problems
Attention, concentration, distractibility Inferiority feelings Self-centeredness
Career concerns, goals, and choices Interpersonal conflicts Self-esteem
Childhood issues (your own childhood) Impulsiveness, loss of control, outbursts Self-neglect, poor self-care
Confusion Irresponsibility Sexual issues, dysfunctions, conflicts, desire differences
Compulsions Judgment problems, risk taking Shyness, oversensitivity to criticism
Decision making, indecision, missed feelings, putting off Legal matter, charges, suits Sleep problems - too much, too little, insomnia, nightmares
Delusions (false ideas) Loneliness Smoking and tobacco use
Dependence Marital conflict, distance/coldness, infidelity/affairs, remarriage Spiritual, religious, moral, ethical issues
Depression, low mood, sadness, uncontrollable crying Memory problems Stress, relaxation, stress management, stress disorders, tics
Divorce, separation Menstrual problems, PMS, menopause, PCOS Suspiciousness, distrust
Drug use - prescription medication, over-the-counter medications, street drugs Mood swings Suicidal thoughts (*Please contact emergency services listed below if immediate assistance is needed)
Eating problems - overeating, undereating, appetite, vomiting Motivation problems Temper problems, self-control, low frustration tolerance
Emptiness Nervousness, tension Thought disorganization and confusion
Failure Obsessions, compulsions (thoughts or actions that repeat themselves) Threats, violence
Fatigue, tiredness, low energy Oversensitivity to rejection Weight and diet issues
Fears, phobias Pain, chronic Withdrawal, isolating
Financial or money troubles, debt, impulsive spending, low income Panic or anxiety attacks Work problems, employment, workaholism/overworking, can't keep a job, dissatisfaction, ambition
Friendships Parenting, child management, single parenthood Other, please describe

If you require IMMEDIATE ASSISTANCE when a counselor is not available:

Please make use of the following resources:
  • Call 911
  • Call the National Suicide Prevention hotline: 1-800-273-TALK(8255)
  • Go to the Emergency Room at Abraham Lincoln Memorial Hospital, 200 Stahlhut Drive, Lincoln, IL 62656
  • Contact an RA or Resident Hall Director
  • Talk with a trusted faculty or staff member
  • Contact a Counseling Center from the list below (Please note: Referral to these sites is not a global endorsement by LCU. Engagement in therapy services, as with any medical or mental health treatment, is done at the client’s own risk.):
  1. Lincoln Pastoral Counseling Services
    1700 North Jefferson Street, Lincoln, IL 62656
    (217) 732-6225
  2. Heartland Christian Counseling
    1520 E College Avenue #M, Normal, IL 61761
    (309) 261-6831
  3. Living Hope Counseling Center
    3000 Lenhart Road
    Springfield, IL 62711-9203
    (217) 698-7150
  4. Christian Psychological Associates
    3716 West Brighton Avenue
    Peoria, IL 61615-2938
    (309) 692-7755
  5. Decatur Psychological Associates
    3040 N University Ave #2
    Decatur, IL 62526-1393
    (217) 872-1700