Request for Initial Appointment

This information is used only for the purpose of assigning a counselor.

All information will be kept strictly confidential.




Counseling appointments are approximately 50 minutes and are free of charge to Lipscomb students.

Note: Appointment times are scheduled Monday – Friday between 8:00 a.m. and 5:00 p.m. Weekly appointments are scheduled for the same day and time each week. We will try to give you an appointment time you prefer, but given the number of people we are trying to accommodate, 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 (*). Please list ALL the times you can be available.




Have you previously been involved in counseling?
Are you in treatment with another counselor at this time?
Have you ever been hospitalized for mental health reasons?
Have you ever served in the military?
Have you ever been treated for any type of chemical dependency?
Is there a history of alcohol or drug problems in your family?
Is there a history of mental health problems in your family?