Counseling Request Form

Please use this form to brief us on how we can best serve you.

Student Name Student Name First Last
Student Cell Phone Number Student Cell Phone Number - ### - ### ####
Student Email
Availability for Appointment (Ex: Mondays from 1-4 pm)
Nature of Counseling Desired

Nature of Counseling Desired Personal Career Academic All of the Above
Delivery Preferred

Delivery Preferred Virtual In-Person Virtual (Evenings 4-9, Monday or Tuesday, Graduate Counseling Student Interns)
Counselor Requested

Counselor Requested Jane Owen, LCSW Ed Sutter, MSEd, LPC, NCC Mary Hamilla, NCC, LPC Timothy Thunberg, NCC, LPC Sarah Bell, NCC Alyssa D'Alessandro, Graduate Intern Jarad Lewellen Sports Psychology/Counseling Intern Ken Cairns, PhD No Preference

Please note that while we try to accommodate this request, scheduling may limit us.