Contact Us Form

Full Name: *

Status: *

Freshman Sophomore Junior Senior Graduate Continued Education

Commuter: *

Yes No

Resident: *

Yes No

If so, where do you live?:

Email: *

What is your question? Place free days & times here: *

Check all the problems that are bothering you: *

Depression Anxiety School Problems Family Problems Relationship Problems Homesickness Sexual Assault Alcohol/Drug Issues Disordered Eating Suicidal Thoughts Anger Procrastination Grief/Loss Self Harm Sexual Identity Issues Other

If you answered other please specify:

This appointment is a: *

If mandated, who mandated you?:

IN ORDER TO SET UP AN APPOINTMENT. YOU MUST STOP BY THE OFFICE AND FILL OUT THE IN-TAKE FORMS AND THEN AN APPOINTMENT CAN BE SCHEDULED. PLEASE BE ADVISED THAT ALL INFORMATION CONTAINED IN THIS WEBPAGE IS MEANT FOR INFORMATIONAL PURPOSES. IT IS IN NO WAY A REPLACEMENT FOR OR ALTERNATIVE TO COUNSELING SERVICES.

CONTACT US FORM

Offices & ServicesWellness CenterCounselingContact UsContact Us Form