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Counseling Services Request Form

Counseling Services Request Form

This form will allow you to request an appointment with Counseling Services. You will receive an email from a MSOE Counseling Services staff member based on your response. 

If you are experiencing a mental health emergency, please call Public Safety if you are on-campus (414-277-7159) or 911 if you are off-campus.

* = required field

Full (Legal) Name *
Preferred Name *
Phone Number *
Student Status *
Have you been diagnosed with a mental health condition(s)? *
Do you have a history of suicidal thoughts and/or behaviors? *
If "yes" to the previous question, have you experienced suicidal behaviors and/or suicidal thoughts with intent to act in the last 24 hours? *
Symptoms/concerns you have (check all that apply) *
The type of support I think I am looking for at this time is... (This will be discussed further when you meet with a counselor.) *

Within 48 business hours of you submitting this form, a staff member will reach out to you via email to discuss next steps. Thanks!

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