Lipscomb UCC Consultation Request Form

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Please go to the UCC Website for the new consultation request form https://www.lipscomb.edu/student-life/health-wellness/counseling-center

Date of Request *

YYYY

Full name (First, middle, and last) *

Date of Birth *

YYYY

Lipscomb E-mail *

Phone number: *

Dorm or local address: *

Emergency contact name and phone number: *

Race and/or Ethnicity *

Gender & Pronouns *

Major *

Sexual Orientation *

Religious Affiliation *

Are you enrolled as a student at Lipscomb? *

Yes, as a undergraduate student

Yes, as a graduate/professional student

Classification

(i.e. Freshman, sophomore, junior, senior, grad student)

If you are a student, when do you intend to graduate? (If this question does not apply to you, please type "n/a") *

Are you employed by Lipscomb? *

Yes

Marital Status *

Married

Divorced

Separated

Single

Please list your hours of *availability* throughout the week. DO NOT LIST CLASS SCHEDULE. Note that we are open Monday-Friday from 8 AM to 5 PM with sessions starting on the hour. After the consultation, if you are scheduled for regularly occurring counseling appointments, they will be scheduled weekly for the same day and time. Please list ALL available times throughout the week. *

If applicable, who referred you to the UCC?

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