*Note: This is an application form for MSU Newman students only.

First Name *

Last Name *

Email *

Phone *

What can we help you with?

How long have you been struggling with this?

Have you had any recent thoughts of harming yourself or others?

Consent *

18 or older

Under the age of 18

If you are under the age of 18, please add your parent/guardian name and email/phone

If this is an emergency please call 911 immediately. Responses are not guaranteed to be immediate, but we will get in touch soon.

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