Counseling Services Applications Please do not click submit multiple times. Please wait for the page to refresh and display the confirmation message after submitting the form. Are you a returning client? Yes No First Name Last Name B# Email Phone Can we leave a message? Yes No Mobile Can we leave a message? Yes No Address City State Zip What days/times are you available for appointments? (Check all available) Monday Tuesday Wednesday Thursday Preferred method of Counseling Support Session Face to Face Session TeleHealth Session Have you had mental health counseling in the past? Yes No Are you currently on any medication? Yes No If yes bring name of medication with you at first appointment. Were you referred by someone on campus? Yes No If yes please indicate whom Why were you referred? Please describe why you want to receive counseling services? Emergency Contact Emergency Contact Phone Emergency Contact Relationship Message Please do not click submit multiple times. Please wait for the page to refresh and display the confirmation message after submitting the form.