Franciscan University of Steubenville
Wellness Center
Request for Counseling Services
Last Name: ________________ First Name: ________________ Student ID #: ___________
Today’s Date: _________________ Semester/Year: _________________
Sex: □ Male □ Female Date of Birth: ___________________ Age: ________
Living Situation: □ Residence Hall _______________ Room #_______ Mail Box # ________
□ Off-Campus Address____________________________________________
Phone: □ Mobile: __________________ □ Landline (if applicable) __________________
May we text message you appointment reminders? If yes, please provide your mobile phone
carrier/provider (e.g., AT&T, Verizon, T-Mobile, Sprint, etc.): _______________________
Preferred Email: _____________________________________
Academic Year: □ Freshman □ Sophomore □ Junior □ Senior □ Graduate
Major: ___________________________________________________________________
Referral Source: □ Self □ Other (specify): _________________________________________
Emergency Contact: Name __________________________ Phone ______________________
Your Home Address: ________________________________________________________
_______________________________________________________
Reason for requesting counseling: _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you had previous counseling here? □ No □ Yes, with ___________________________
*you may request a specific counselor, but we may not be able to accommodate your request
OFFICE USE ONLY
Counselor Assigned: ________________________________ Type: □ New □ Returning
Date/Time of Contacts: ______________________________
Last Updated: 07/20/17
Name: _________________________________
Directions: please mark the days and times of when you are available to meet
for counseling. Evening hours (5:00 PM to 8:00 PM) vary from semester to
semester.
Time
Monday
Tuesday
Wednesday
Thursday
Friday
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
Franciscan University of Steubenville
Wellness Center Counseling Services
Phone: (740) 284-7217
Greetings,
Thank you for your interest in counseling services from the Franciscan University of
Steubenville Wellness Center. One of our counselors will be in contact with you soon to
schedule an appointment. We ask that you:
be on time for your appointments
check in with our secretary when you arrive, paying any fees due
notify us as soon as possible if you have to cancel an appointment
respect the confidentiality of all other students in the Wellness Center
Be aware that:
if you miss appointments frequently, you may lose your scheduled weekly appointment
time
your counselor may ask you to join a counseling group in place of or in addition to one-
on-one counseling
If you have any questions, comments, or concerns, you may contact me via telephone (740) 284-
7217 or email [email protected].
God Bless,
Matthew Burriss, MA, LPCC-S
Director of the Wellness Center
