If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, DO NOT complete this form. Please contact your campus counseling center 24/7 support line or call 911.
We request the following information as a quick and convenient way to refer you to an appropriate professional. Our questions screen for your health and safety, which is our primary concern. Please do not complete a request for another adult (18 years or older) for individual counseling, they MUST complete the request themselves. If you are requesting services for a minor child, please include your name, date of birth, relationship to the student, and contact information in the Additional Comments Section. If this is for a minor child, please anticipate that a representative from your Assistance Program will be in touch.
A Student Assistance representative will reach out to you within one business day with regard to your on-line request.