Counseling Inquiry Form | Goodwin University

Name

Student ID

Cell Phone

Home Phone

Email (in case we miss your call)

Date of Birth

Gender

Female

Male

Other

Have you used any of our services before?

Yes

No

Inquiry (check all that apply)

Self-referred to speak with a counselor

Faculty/Staff-referral to speak with counselor

Addiction

Depression

Experiencing Anxiety

Experiencing Grief & Loss

Other

If other, please explain

When would be a good time to reach you?

Morning: 8 a.m.-1 p.m.

Afternoon: 2-7 p.m.

Preferred day and time for appointment?

Additional Comments

I understand that counseling at Goodwin University is provided by Integrated Health Services (IHS). I am giving my consent to have this information passed along to them.

If you are human leave this field blank