Counseling Request Form

Counseling Request Form
Is this a crisis?*

YesNo
If you are experiencing a mental health emergency and it is after business hours, please call Campus Police 1-814-886-6327, 911, or Cambria County Crisis at 1-877-268-9463.
Student Name*

First NameLast Name
Student MAC Email*
jdoe123@student.mtaloy.edu
Student Phone Number*

Area CodePhone Number
Referral Source:*

SelfFriendProfessorStaffOVROther
Reason(s) for seeking help:*

Severity of current stressors:*

	1	2	3	4	5	6	7	8	9	10

1 is Lowest, 10 is Highest