Full Name (required)

Date (required)

Semester/Year (required)

Gender MaleFemale

Date of Birth

Age

Residence Hall

Room Number

Mailbox Number

Phone

E-mail

Is it ok to leave message on answering machine YesNo

Is it ok to leave a message with a roomate YesNo

Local Address (if off campus)

Current Marital Status

Name of Spouse (if applicable)

Number of Dependents

Ages

Academic Class FreshmenSophmoreJuniorSenior

Major

Referral Source SelfOther

Emergency Information

Contact Name

Relation

Phone Number

Your Permanent Address

Reason for seeking counseling

Have you ever had previous counseling YesNo

If yes, with whom?

Please list Times Available