Emmanuel University Student - Request for Counseling Services
Date of Request:
-
Month
-
Day
Year
Date
EU ID #:
First & Last Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Age:
Gender:
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Briefly describe your reason for seeking counseling services:
Enrollment Status (Select One):
Option 1: I am an EU student living on the Emmanuel University campus in Franklin Springs
Option 2: I am an EU student who commutes to campus.
Option 3: I am an EU student attending fully remote/online.
If selecting Option 2 or Option 3, please list which state you currently live in:
Telehealth Services:
Telehealth services are counseling services provided virtually through a secure online platform.
Is telehealth an acceptable option for you?
Yes
No
Which method of care do you prefer?
In-person counseling
Telehealth counseling
No preference
Important Notice - Not an Emergency Service
This request form is not monitored for emergencies and should not be used if you are experiencing a crisis.
If you are in immediate danger, experiencing a life-threatening emergency, or having thoughts of harming yourself or others,
do not submit this form
. Please call
911
or go to the nearest emergency room immediately.
Eligibility & Fees (Emmanuel University Students)
Currently enrolled Emmanuel University students are eligible for three (3) counseling sessions at no cost, covered by Emmanuel University.
If additional counseling services are recommended beyond the three initial sessions, the student will be responsible for payment. Subsequent sessions may be self-paid or billed through the student's insurance, if applicable.
Submission of this form does not guarantee immediate service and does not establish a counselor-client relationship until contact has been made and services are confirmed.
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