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» Student Counseling Center
SCC - Request an Appointment
SCC - Request an appointment
Fill out the information below and information will be confidentially transmitted directly to the Student Counseling Center. Someone will respond to your email within 24 hours.
1.
What is your name?
2.
What is your Social Security Number?
3.
May we contact you through your home telephone?
Yes
No
4.
Home phone number
5.
May we leave a message for you on your home phone?
Yes
No
6.
If you have a cell phone, may we contact you through your cell phone number?
Yes
No
7.
Cell phone number
8.
May we leave a message on your cell phone?
Yes
No
9.
May we contact you by email?
Yes
No
10.
Email address
11.
Which college do you attend?
College of Nursing & Health Professions
College of Medicine
Public Health
Arts & Sciences
Other
12.
Have you ever received psychological services?
Yes
No
13.
Have you ever received services from us before?
Yes
No
14.
What hour blocks do you generally have available to meet on MONDAYS?
15.
What hour blocks do you generally have available to meet on TUESDAYS?
16.
What hour blocks do you generally have available to meet on WEDNESDAYS?
17.
What hour blocks do you generally have available to meet on THURSDAYS?
18.
What hour blocks do you generally have available to meet on FRIDAYS?
19.
What are the reasons you are seeking help at this time?
*
denotes a required field
Modified:
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