Request for Counseling Services

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Name*

Date of Birth*

Student ID*

Contact Preference (Email or Phone)*Enter UNTD email or your phone number

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

Yes

Are you currently 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 immediate crisis?*

Yes

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

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

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Request for Counseling Services