Counseling Services Waitlist Form
Please provide your details below to be placed on the counseling services waitlist. All fields help us match you with the best available counselor and appointment options.
Full Name
*
First Name
Last Name
Preferred Pronouns
*
Please Select
She/Her
He/Him
They/Them
Other (please specify)
Prefer not to say
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone Call
Text Message
Reason for Seeking Counseling / Brief Support Needs
*
Preferred Counselor Gender
*
No preference
Female
Male
Non-binary
Preferred Appointment Format
*
In-person
Video call
Phone call
No preference
Preferred Days and Times for Appointments
*
Weekday mornings
Weekday afternoons
Weekday evenings
Saturday
Sunday
No preference
Additional Notes or Scheduling Constraints
Join Waitlist
Should be Empty: