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Counseling Resource Center

Appointment Request Form

2. Please select one: *This question is required.
3. How would you prefer to be addressed when we contact you?
5. What do you need assistance with? Please select all that apply. *This question is required.
6. How may we contact you?
This question requires a valid email address.
7. Please select any/all that apply to you (please see descriptions below):
  • Single parent: An individual who is not married and has custody of and is responsible for the care of one or more minor children, or an individual who is not married and is currently pregnant.
  • ​​​​​​Displaced homemaker: An individual who has been out of the job market for a period of time and now needs to return to work for financial reasons due to separation, divorce, disability, or the death of a spouse.
  • Limited English proficiency: An individual whose native language is a language other than English.
  • Economically disadvantaged: A credit-hour student who is a needs-based financial aid recipient of Pell or Temporary Aid to Needy Families (TANF).
  • Student in a non-traditional career program: Non-traditional occupations are those in which one gender makes up less than 25% of the total number of workers (ex: female welding student or male nursing student).​
  • ​​​​​​Student with disabilities: An individual with a physical or mental impairment that substantially limits one or more major life activities, such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.