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Note: This is an application form for MSU Newman
students only.
First Name
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Last Name
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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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