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We Are Pioneers
Alumni
Request for Counseling Services
Request for Counseling Services
"
*
" indicates required fields
Name
*
First
Middle
Last
Preferred Name/Nickname
First
Middle
Last
Tusculum Email
*
Alternate Email
Student ID
Major
Cell Phone
Alternate Phone
Classification
Freshman
Sophomore
Junior
Senior
Graduate Student
Campus
Greeneville
Knoxville
Morristown
Online
Are you currently enrolled? If no, list anticipated start date
*
Yes
No
Other
Please select the reasons you are requesting Counseling Services
*
Coping with stress
Dealing with trauma such as intimate partner violence, abuse or assault
Troubled past
Substance use
Improving mood to decrease depression
Ways to manage anxiety
Coping with grief
Adjustment to college
Improving relationships
Understanding sexual orientation or identity
Other
Select All
If other selected, please explain here.
Do you consider yourself spiritual or religious?
*
Yes
No
Do you have spiritual beliefs that help you cope with stress?
*
Yes
No
Would you like to incorporate your spiritual or religious beliefs in your counseling services
*
Yes
No
Select the format of counseling in which you would participate. Check all that apply.
*
Individual counseling (sometimes called "therapy") is a process through which students work one-on-one with a counselor.
Group counseling is a process through which a small group of people (generally 6-10) meet face-to-face with a trained group counselor to talk about a particular issue with which all of them need assistance.
Educational counseling is a small group of people meeting face-to-face with a trained group counselor to explore and develop skills around a particular topic in which all of them would like to learn.
Consent
*
I agree to the below Counseling Request for Services Statement.
On the indicated date, I, the undersigned, submitted this request for counseling services.
Tusculum is committed to offering students with the opportunity to meet with a professional counselor in a confidential atmosphere at no cost to the student for short-term care or referral. The participation in counseling is completely voluntary, and students may terminate services at any time. Completing this form and meeting with a counselor are the first steps to receive counseling/mental health treatment services.
Once my file has been reviewed, a staff person from Counseling and ADA Services will contact me within five business days to schedule an initial counseling appointment. I understand I may be asked to complete behavioral health inventories to guide services.
Name
*
First
Last
Date
*
MM slash DD slash YYYY
