UM - New Student Online Forms

Name*

First NameLast Name
Student ID*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Sexual Orientation*
Email*
example@example.com
Local Address (If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a Veteran?*
Are you a Smoker?*
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred?*
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred?
Primary Language Spoken in the Home*
How did you hear about us?*
Race*
If Other
What would you like to focus on in counseling?*
YesNo
YesNo
YesNo
If you are experiencing thoughts of hurting yourself or others please call 911 immediately.
EMERGENCY CONTACT: By filling in the information below, I give permission to speak to my Emergency Contact if necessary
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address
Relationship to you*
Medical and Counseling Information
Are you being treated for any medical condition?*
If yes, Describe
Are you taking medications?*
If yes, Name and Dosage
Reason for medications
Name of Doctor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever been in counseling before?*
If yes, dates

MonthDayYear
Date
With Whom
Have you ever been hospitalized before?*
if yes, dates

MonthDayYear
Date
If yes, for what?
YesNo
Yes
YesNo
YesNo
Telehealth Consent Form
Please Upload 2 Files, Picture of your Government Issued ID and Student ID
Picture of government issued ID*

Cancelof
Picture of your student ID*

Cancelof
Should be Empty:

If you are experiencing thoughts of hurting yourself or others please call 911 immediately.