Request for Counseling Services

Please don't fill out this input box.

Full Name*

Are you an undergraduate or graduate student?*

Date of Birth*

Student ID*

UNT Dallas Email*Enter UNTD email

Phone Number*Provide best number to reach you

If necessary, may we leave a message and email identifying ourselves?*

Yes

Are you enrolled in at least one class this semester?*

Yes

Note that if you are not currently enrolled in at least one class at UNT Dallas you will not be eligible for services. If you need assistance finding alternate resources email Counseling.Wellness@untdallas.edu

Are you in crisis (ex: experiencing thoughts of self-harm, suicide, harming others, or so emotionally distressed that you believe you cannot keep yourself safe)??*

Yes

If you are in immediate danger do not proceed with this form. Call 911 or get to your nearest hospital.

Brief Statement of Problem*

Weekday Availability*The Counseling & Wellness Center is open Monday through Friday, 8am to 5pm.

Do you prefer in-person or virtual sessions?*

If you have received counseling services in the Counseling & Wellness Center in the past, who was your counselor?

Would you like to be assigned the same counselor as before?

Yes

If you have not received services previously you will be assigned to the first available counselor.

How did you hear about counseling services?*

UNT Dallas Website

Class Presentation

Staff

Faculty

Social Media

Campus Event

Other