Counseling Center for Wellness

Intake Form


Prior to your first visit, you may complete the Intake Form (PDF). 

The Intake Form (PDF) is a printable PDF, so you may complete it, save it, and email* it as an attachment to Fritz Haas.


OR you may complete the form, print it out, and bring it with you. 

* Please understand that we cannot guarantee your confidentiality if submitted electronically, as email is not considered to be a secure medium.

All aspects of your participation in counseling at the Counseling Center for Wellness, including the scheduling of appointments, contents of counseling sessions, all contents of counseling records and outcomes of counseling are confidential by state law. They are not a part of your academic record. Your counselor will address any questions you have about this important issue.