Mental Health Services Referral Form

This referral request is for:

myself someone else

Student Name*

First Name

Middle Name

Last Name

Student ID #*

Student Phone #*

Must be a working #.

Referred by (if other than self):

First Name

Last Name

Email*

Northeast Extension

Reason for referral: *

Requesting student is referred to: *

Success Center, Leigh Ann Stewart Vice President of Student Services, Ray Scott Campus Police, Anthony Anderson

Contact Information

Leigh Ann Stewart
Success Center, Wright Hall
662.720.7192
lastewart@nemcc.edu

Ray Scott
Vice President of Student Services, Ramsey Hall
662.720.7235
jrscott@nemcc.edu

Anthony Anderson
Campus Police, Frank Haney Union
662.720.6687
campuspolice@nemcc.edu

In compliance with Title VI of the Civil Rights Act of 1964; Title IX, Educational Amendments of 1972 of the Higher Education Act; and, Section 504 of the Rehabilitation Act of 1973, as amended, the Board of Trustees of Northeast Mississippi Community College has adopted this policy assuring that no one shall, on the grounds of race, color, age, national origin, or sex, be excluded from participating in, be denied the benefits of, or otherwise be subjected to discrimination in any program or activity of the College. Northeast Mississippi Community College adheres to the principle of equal educational and employment opportunity without regard to race, sex, age, color, creed, or national origin. This policy includes the qualified handicapped and extends to all programs and activities supported by the College. The Section 504 Coordinator is Leigh Ann Stewart, Wright Hall (662)720-7192 and the Title IX Coordinator is Liz Roark, (662)720-7223.

For Office Use Only:

Received by: ______________________________________

Date received: _____________________________________