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Client Counseling Referral Form
New Student Registration
Student First and Last Name
*
First Name
*
Last Name
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Email Address
*
Cell Phone
*
Please share why you are seeking counseling:
*
Symptoms (Check all that apply)
*
Academic Issues
Anger Issues
Anxiety/Panic
Depression
Family Relationship Issues
Grief and Loss
Peer Conflict
Romantic/Relationship Issues
Roommate Issues
Social Issues
Substance Abuse
Time Management
Other:
Other Value
School Information
*
Freshman
Sophomore
Junior
Senior
Student Type
*
Resident - Full-Time
Resident - Part-Time
Commuter - Full-Time
Commuter - Part-Time
Major and GPA
*
Preference
Please provide three options. AM (9-11) (PM 1-4)
*
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Have you attended counseling before?
*
Yes
No
Have you attended counseling at Thompkins Health Center? If so, who was your counselor?
Do you have any counselor preferences? (ex: age, race, gender, etc.)
*
Referred by:
*
Self
Staff
Faculty
Parent/Guardian
Friend
Other:
Other Value
Emergency Contact
Emergency Contact
*
First Name
*
Last Name
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Cell Phone
*
Relationship to you
*
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