Kent State Stark Counseling Services Request

COUNSELING SERVICES APPOINTMENT REQUEST

Kent State University at Stark

There is not a counselor on staff at the Stark Campus effective June 1, 2023. Please check back at a later time for availability of services.

Thank you for contacting Counseling Services to schedule an appointment. When you submit the request form below, the office will confirm your enrollment status and contact you by phone to discuss services. By providing contact information, you are also providing consent for Counseling Services to contact you using that information.

If you feel that you cannot wait to be contacted, or are having current thoughts of wanting to harm yourself, please call the Stark County 24-Hour Crisis Hotline at 330-452-6000, the Suicide and Crisis Lifeline at 988, or text "4hope" to 741-741 to immediately connect with emergency or crisis support services.

Your Information:

First Name/ Preferred Name:

Last Name:

Kent State ID Number:
(9-digits; begins with an 8)

Street Address:

City:

State:

Zip Code:

Phone:

Email:

Emergency Contact Name:

Emergency Contact Phone:

What is the primary Kent State University campus you attend (Stark or Tuscarawas)?

Are you taking at least 50% of your Kent State classes at the Stark Campus?

Yes
No

Briefly describe why you are interested in counseling services:

Indicate days and times you would be available to come in for an appointment:

**Indicate days and times you would be available to come in for an appointment:**
			Monday	Tuesday	Wednesday	Thursday	Friday
Times Available (2-4 p.m., 10-10:30 a.m., etc.)			Times Available (2-4 p.m., 10-10:30 a.m., etc.)

I was referred to Counseling Services by:

Self

Family

Professor

Friend

Staff / Administrator

Other

Are you in need of any accessibility accommodations in order to participate in counseling?
(such as an interpreter, enlarged text, electronic versions of paperwork, etc.)

No
Yes; please indicate:

For Tuscarawas students ONLY:

The Tuscarawas campus has an office space available to reserve for use to maintain privacy and confidentiality during counseling sessions. Will you need to use this space for sessions?

Yes
No
N/a Stark campus student