Appointment Form - Counseling Center | Lipscomb University

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Appointment Form

Counseling Center > Request Appointment > Appointment Form

Request for Initial Appointment

THIS INFORMATION IS USED ONLY FOR THE PURPOSE OF ASSIGNING A COUNSELOR.

ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL.

* Student ID (L#) _REQ
* First Name _REQ
Middle Name
* Last Name _REQ
Maiden Name
* Please check the appropriate box: _REQ	I am currently a student at Lipscomb University I am currently employed by Lipscomb University I am an alumnus of Lipscomb Univeristy (Students and employees receive priority scheduling; alumni may be accommodated when therapists’ schedules permit. In such cases, counseling services for alumni are normally limited to career counseling and pre-marital counseling.)
* Date of Birth _REQ
* Gender _REQ	Male Female
Counseling appointments are approximately 50 minutes and are free of charge to Lipscomb students. Appointments are scheduled Monday-Friday between 9:00 a.m. and 3:30 p.m. We will try to give you an appointment time you prefer, but given the number of people we are trying to accomodate and the limited number of counseling hours available, we need to know all the times you can be available. You may indicate preferred times with an asterisk (*).
MWF Mornings
MWF Afternoons
TR Mornings
TR Afternoons
Briefly describe the concerns you would like to discuss with a counselor
Other information or comments to help us meet your needs
Preferred Method of Contact:	Phone E-mail
Phone
* E-mail Address _REQ
* Type both words below, separated by a space. Can't read the words below? Try different words or an audio captcha.

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