Date: _________________ Name: _____________________________________________ DOB: _____________________ Age: ______________

Bengal ID: ____________________________________ Phone: _____________________ E-mail: _______________________________________

Referring person: ____________________________________ Phone: _____________________ E-mail: _________________________________

HEALTHY BENGALPlease complete this form to refer an individual to the ISU program or clinic you feel would be most appropriate and helpful. If the person you are referring is interested, please assist in sched-

uling an appointment. If they decline your help, he/she should take the referral form and it is their responsibility to follow up with the program or clinic and schedule an appointment when they desire. Confidentiality will be protected by FERPA and HIPAA policies.

Serving the Bengal Family

Campus Recreation*Student Recreation CenterRoom 360 • (208) 282-4854

Fitness equipment and programs‡Massage therapy†‡Personal training†‡

Center for New Directions#Roy F. Christensen BuildingRoom 372 • (208) 282-2454

Career counseling servicesPersonal counseling servicesSingle parent support services Non-traditional occupation support services

Central Academic AdvisingPocatello: (208) 282-3277Museum Bldg, Room 307Idaho Falls: (208) 282-7800Bennion Student Union

General Education requirements informationMajor or minor selection

Dietetic Programs(208) 282-2961 or (208) 282-3091

Nutrition questionsEating concerns

Disability ServicesPocatello: (208) 282-3599Rendezvous, Room 125Idaho Falls: (208) 282-7759 Bennion Student Union, Room 223

Disability accommodations

Janet C. Anderson Gender Resource CenterRendezvous, Room 235 • (208) 282-2805

Identity explorationSexual assault/relationship violence

University Counseling and Testing ServicePocatello: (208) 282-2130351 Gravely Hall South, Room 351Idaho Falls: (208) 282-7750Bennion Student Union, Room 223Free and confidential individual, group, and couple counseling for currently enrolled ISU students

Stress Management & Biofeedback Center (operated by University Counseling and Testing Service)

Reduce anxiety/stressDecrease tension/painSleep difficultiesPromote relaxationImprove awareness of mind and body

Wellness Center*Reed Gym, Room 205A • (208) 282-2117

Fitness assessments‡GET-FIT Program†‡Personal training‡Wellness coaching‡

*This program offers many free services to students, but some services require a reasonable fee.

†This service is available for a reasonable fee to students.

‡This service is available for a reasonable fee to faculty and staff.

#This program is available for College of Technology students only.

LOCATIONPocatelloIdaho Falls

Pocatello | Idaho Falls Meridian | Twin Falls

Bengal LabLeonard Hall, Room 161 • (208) 251-6260

Diagnostic testingDrug testingScreening tests (i.e., HIV, HCV)Wellness testing (i.e., CBC, lipid, and chem panels)

Bengal Pharmacy990 Cesar Chavez Ave (above the ISU Health Center) • (208) 282-3407

Medication therapy and education

Dental Hygiene Clinic999 Martin Luther King Jr. Way(208) 282-3282

Preventive careBleach traysCleaningsFillingsFluoride applicationOral health educationPeriodontal therapySealantsX-rays

Health West ISU Clinic465 Memorial Drive • (208) 234-4700Services available on a sliding-fee scale

Laboratory servicesMedical care

ISU Health CenterPocatello: 990 Cesar Chavez Ave • (208) 282-2330Idaho Falls: Bennion Student Union • (208) 282-7826

Laboratory servicesMedical careMedical nutrition therapy (Pocatello)X-ray services

ISU Hearing and Balance ClinicCommunication Sciences and Disorders Building • (208) 282-3495

Auditory processing evaluationBalance/dizziness evaluationCochlear implant servicesHearing aid servicesHearing evaluationTinnitus evaluation

ISU Physical and Occupational Therapy Associates and Balance ClinicGarrison Hall, Room 202 • (208) 282-2590

Balance/dizziness evaluation Emotional self-regulationErgonomic work place assessmentsHome safety assessments Joint health: injuries (sprains and strains)Post-surgical careRepetitive strain injuries (carpal tunnel syndrome)Sensory processing issuesWomen’s health (continence) Written communication/penmanshipVisual fine motor integration

ISU Pocatello Counseling ClinicIndividual, couple, and family counseling available on a sliding-fee scaleGarrison Hall, Room 725 • (208) 240-1609

AnxietyDepressionGrief/lossImprove wellness strategiesRelationship concernsSocial anxiety/communicationStress managementOther personal/emotion concerns:

ISU Psychology ClinicIndividual, couple, and family counseling available on a sliding-fee scale Garrison Hall, Room 533 • (208) 282-2129

Treatment for depression, anxiety, and other DSM-5 DisordersTreatment for impulse control difficultiesTreatment for trauma-related problems and interpersonal/relationship issuesAssessment and treatment for externalizing and internalizing problems in children and adolescents, including specializations in feeding difficulties, selective mutism, developmental disabilities, and Autism Spectrum DisordersChild and adult evaluations for ADHD, learning disorders, and intellectual disabilities

ISU Speech and Language ClinicCommunication Sciences and Disorders Building • (208) 282-3495Services available on a sliding-fee scale

Accent modification/reductionAlternative and augmentative communication Articulation receptive and expressive languageAdult brain injury therapy (TBI and stroke)Preschool Language ProgramStuttery/fluencyVoice therapySwallowing therapy

Pocatello Family Dentistry465 Memorial Drive • (208) 282-6000Services available on a sliding-fee scale

Hospital dentistryImplants Endodontics (root canals)Oral surgeryPediatric dentistry Preventive care Prosthodontics (crowns, bridges and dentures)

HEALTHY BENGAL------------------------------------------------------------------ Fee for Services ------------------------------------------------------------------