I need to speak to a counselor for:
Personal ProblemsAcademic ProblemsMarital/Couples TherapyConsultation About a Clinic PatientOutside ReferralOther


Please list times you would be available to see a counselor (M-F, 8-5).
Please list several possible times.



How would you like to be contacted by:


On a scale of 1-10, how urgent would you rate your current problems (10 being an emergency)?



jrodriguezCounseling Request Form