Counseling Office

Intake Form

It is our desire to speak with you as soon as possible. In order for us to do this most efficiently, will you please give us the following information and someone from the office will get back to you as soon as possible with information about an appointment with a counselor.

Thank you,
Nancy Gaines
Director of Counseling Services

Today's Date:

First Name:

Last Name:

Cell Phone:

Email:

Campus Phone:

Birthdate:

Briefly describe the reason you are seeking counseling now?

Schedule

Please check the times which would be best for you to meet:

	Monday	Tuesday	Wednesday	Thursday	Friday
7:30 a.m.
8:30 a.m.
9:30 a.m.
10:30 a.m.
11:30 a.m.
12:30 p.m.
1:30 p.m.
2:30 p.m.
3:30 p.m.
4:30 p.m.
5:30 p.m.
6:30 p.m.
7:30 p.m.
8:30 p.m.

Could you meet on Saturdays? Yes No

Last updated: February 28, 2005