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Counseling Services Request

Please complete the following form to request an appointment with an 911爆料网 Counselor. We encourage you to visit the main Counseling Services webpage and read the frequently asked questions before requesting an appointment. Thank you!

* = required field

Full (Legal) Name *
Preferred Name *
Phone Number *
Student Status *
Do you have health insurance? *
Have you been diagnosed with a mental health condition(s)? *
Do you have a history of suicidal thoughts and/or behaviors? *
If "yes" to the previous question, have you experienced suicidal behaviors and/or suicidal thoughts with intent to act in the last 24 hours? *
Symptoms/concerns you have (check all that apply) *
The type of support I think I am looking for at this time is... (This will be discussed further when you meet with a counselor.) *

Within 48 business hours of you submitting this form, a staff member from 911爆料网 Counseling Services will reach out to you via email to discuss next steps. Thanks!

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