Counseling Request Form
Section 1: Personal Information
Full Name
Student ID Number
Email Address
Phone Number
Program of Study
Please Select
CHC30121 Certificate III in Early Childhood Education and Care
CHC50121 Diploma of Early Childhood Education and Care
BSB50120 Diploma of Business (Digital and Data)
BSB60420 Advanced Diploma of Leadership and Management
BSB80120 Graduate Diploma of Management (Learning)
BSB50820 Diploma of Project Management
BSB60720 Advanced Diploma of Program Management
ICT50220 Diploma of Information Technology (Business Analysis)
ICT60220 Advanced Diploma of Information Technology
BSB40820 Certificate IV in Marketing and Communication
BSB50620 Diploma of Marketing and Communication
BSB60520 Advanced Diploma of Marketing and Communication
General English
Section 2: Counseling Request Details
Type of Counseling Needed
Academic Counseling
Personal Counseling
Career Counseling
Financial Counseling
Other (Specify)
If Other, Please Specify
Preferred Counseling Method
In-Person
Online
Phone
Preferred Counselor (If Known)
Section 3: Appointment Details
Preferred Appointment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Appointment Time
Urgency of Request
Urgent
Within a Week
Flexible
Section 4: Additional Information
Brief Description of the Issue or Concern
Previous Counseling Sessions (If Any)
Upload Supporting Documents (Optional)
Browse Files
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Choose a file
If applicable, upload any documents that may help the counselor understand your situation better.
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Section 5: Agreement to Terms
Agreement to Counseling Policies
I have read and agree to Rosehill College’s policies regarding counseling services.
Consent to Data Processing
I consent to the collection and processing of my personal data as described in Rosehill College’s Privacy Policy.
Confidentiality Agreement
I understand that the information provided will be kept confidential and used solely for the purpose of providing counseling services.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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