Counseling Services Inquiry Form

Counseling Services Inquiry Form

Please provide the information requested below. Staff from Counseling Services will receive your request and will respond to your inquiry within one business day to help you schedule an appointment. Please provide as many appointment options on the form below as you can. This will assist our staff in scheduling an appointment for you as promptly as possible.
Name*

First NameLast Name
Email*
example@example.com
Preferred phone number*

Area CodePhone Number
Date of birth*

MonthDayYear
Preferred counselor

Gerald RoothElizabeth KellettJoseph MorrissetteMarievien AquinoAbigail GrassmyerNo Preference

Please select all times that you are available to meet with a counselor in the next week*

Please be aware electronic communication is not guaranteed to be secure. Confidentiality is not assured. Counseling Services does not maintain 24-hour access to email or form submission accounts and may only check email and form submissions infrequently, and not at all on weekends or holidays. If you have an emergency please call Public Safety at (301) 447-5911.
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