Counseling Services Inquiry Form

Counseling Services Inquiry Form
Name *

First Name Last Name
Preferred communication (this is how we will respond to your inquiry)

Email Phone
Email
example@example.com
Phone Number

Area Code Phone Number
Preferred counselor

No Preference Gerald Rooth Alesha Leonard Elizabeth Kellett Eliane Coates
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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