Request for Counseling Services Form

Please complete the form below. All information will be kept confidential as stipulated by law.

Schedule Service Request

Date *

Academic Semester / Year *

Full Name *

Gender *

Date Of Birth *

Age *

Residence Hall *

Room Number *

Mailbox Number *

Local Address (If Off Campus)

Phone Number *

Do We Have Your Consent To Leave A Voicemail Message? *

Yes

Email Address *

Current Marital Status

Name Of Spouse (If Applicable)

Number Of Dependents (If Applicable)

Ages Of Dependents (If Applicable)

Academic Class *

Major *

Referral Source

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Your Permanent Address *

Reason For Seeking Counseling Services *

Have You Received Counseling Services In The Past? *

Yes

If Yes, With Whom?

Please List The Days And Times You Are Available For An Appointment, Being As Flexible As Possible *

Quicklinks