Request for Counseling Services

Please don't fill out this input box.

Full Name*

Are you an undergraduate or graduate student?* Please Select Undergraduate Student 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 identifying ourselves?*

Yes

No

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

Yes

No

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 immediate crisis?*

Yes

No

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

Statement of Problem*

Preferred Meeting Time(s)*

How did you hear about Counseling services?

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

No

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

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