Please fill out the following form, someone from the Student Services Department will reach out to you shortly. If you are in an emergency situation, call 911. 

 

Please complete the form below

Name *
Name
Date of Birth *
Date of Birth
Gender *
Class Standing *
Religious Background
Please describe below.
Personality Information
Mark any of the following words which best describe you now: *
Please rate on a scale of strongly disagree to strongly agree, if you have had the any of the following experiences over the last month. *
Please rate on a scale of strongly disagree to strongly agree, if you have had the any of the following experiences over the last month.
I have felt depressed.
I have felt anxious.
I have been worried.
I have been angry.
I have experienced abuse.
I have felt hurt.
I have felt shame.
I have had suicidal thoughts.
I have experienced a panic attack(s).
I have engaged in addictive behavior.
I have had a relational conflict.
Answer the following briefly:
Describe yourself.