SUSLA Intake Request Form

Confidentiality Statement: The Counseling Center, in compliance with professional ethics and state laws, may release information in the event of a student posing serious harm to self or others.
The Counseling Center may also release academic information as it relates to academic advisement.

First Name: Middle Initial: Last Name:

Current Address:

Street: City/Town: State: Zip:

Home Address:

Street: City/Town: State: Zip:

Reason for Visit Request:

- By checking this box, I am stating that I am here for Academic Advising only and that I fully understand that my academic information may be released.

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