EmailMe Form - Request a Counseling Appointment

Name *

First Last

Student ID # *

Email *

Cell Phone *

### - ### - ####

Year in College *

Type of Appointment *

Have you been a client in our office this academic year? *

Yes

No

Reason for Appointment *

Preferred Appointment

Please make your request of dates one week out if possible.

Preferred Date/Time Choice #1 *

MM / DD / YYYY HH : MM AM/PM

Preferred Date/Time Choice #2 *

MM / DD / YYYY HH : MM AM/PM

Preferred Date/Time Choice #3 *

MM / DD / YYYY HH : MM AM/PM

NOTE: A staff person will be in contact with you within one business day with your appointment time. If this is an emergency, please call Security (319) 352-9999 or 911.