Counseling Inquiry

Fill out the below form to request an appointment with a campus counselor and we will reach out to you as soon as possible.

Name

Student ID

Cell Phone

Home Phone

Email (in case we miss your call)

Date of Birth

Gender

Female

Male

Other

Have you used any of our services before?

Yes

No

Inquiry (check all that apply)

Self-referred to speak with a counselor

Faculty/Staff-referral to speak with counselor

Addiction

Depression

Experiencing Anxiety

Experiencing Grief & Loss

Other

If other, please explain

When would be a good time to reach you?

Morning: 8 a.m.-1 p.m.

Afternoon: 2-7 p.m.

Preferred day and time for appointment?

Additional Comments

If you are human leave this field blank

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