This form will allow you to request an appointment with Counseling Services. You will receive an email from a B次元 Counseling Services staff member based on your response.

If you are experiencing a mental health emergency, please call Public Safety if you are on-campus (414-277-7159) or 911 if you are off-campus.

* = required field

Full (Legal) Name *

First

Last

Preferred Name *

First

Last

Student ID Number *

Phone Number *

###

####

Email Address *

Date of Birth *

Biological Sex (Sex Assigned at Birth) *

Gender You Identify Best With *

Emergency Contact Name (Only Used in Cases of Emergency) *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Student Status *

1st Year

2nd Year

3rd Year

4th Year

5th Year +

Graduate Student

Have you been diagnosed with a mental health condition(s)? *

Yes

If "yes" to the previous question, please describe, including information on whether you are currently receiving treatment for your condition(s). If no, please state not applicable. *

Do you have a history of suicidal thoughts and/or behaviors? *

Yes

If "yes" to the previous question, have you experienced suicidal behaviors and/or suicidal thoughts with intent to act in the last 24 hours? *

Yes

N/A

Please further describe any checked boxes regarding symptoms/concerns. If none, please state not applicable. *

With support from Counseling Services, what would you like to achieve through this request? *

The type of support I think I am looking for at this time is... (This will be discussed further when you meet with a counselor.) *

1-2 meetings to receive support with a specific question or issue

An ongoing counseling relationship where I can address emotional health goals

I'm not sure yet

Please list weekdays (Monday-Friday) and blocks of time (between 8am-4pm) that you are available to meet with someone. Please list multiple blocks of time over several days. *

Within 48 business hours of you submitting this form, a staff member will reach out to you via email to discuss next steps. Thanks!

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