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

ATTENTION: OUT OF OFFICE

The Counseling Services team is currently out of office. Our office will resume regular hours, and we will attend to any correspondence we receive until then, on January 6, 2025. Happy New Year!

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 9am-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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