Counseling Callback Request
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
RIC Email (please be sure to enter your RIC email address)
*
ex: jdoe_9999@email.ric.edu
I am interested in (check all that apply):
*
Group Counseling
Individual Counseling
Community Resources
Optional: Major Concerns at this Time (check all that apply)
Academic Stress
Anger
Anxiety
Adjustment to College
Depression
Eating Concerns
Financial Stress
Identity Concerns
Loss
Relationship Concerns with Family
Relationship Concerns with Friends
Relationship Concerns with Significant Others
Self-Esteem Challenges
Social Anxiety
Trauma
Optional: I would prefer to work with a provider who identifies as (check all that apply)
No Preference
Female
Male
A Person of Color
LGBTQ+
The first in their family to attend college
A Parent
A Spanish-Speaking Provider
Bicultural and Bilingual
An Immigrant/Refugee
Submit
Should be Empty: