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Counseling Services Request

Counseling Services Request

Please complete the following form to request an appointment with an MSOE Counselor. Within 48 business hours of you submitting this form, a staff member will reach out to you via email to discuss next steps. Thanks!

* = required field

Full (Legal) Name *
Preferred Name *
Phone Number *
Student Status *
Do you have health insurance? *
Have you been diagnosed with a mental health condition(s)? *
Do you have a history of suicidal thoughts and/or behaviors? *
If "yes" to the previous question, have you experienced suicidal behaviors and/or suicidal thoughts with intent to act in the last 24 hours? *
Symptoms/concerns you have (check all that apply) *
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.) *

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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