Milligan Counseling Center Referral & Appointment This form is used to schedule appointments with the counseling center. Step 1 of 2 50% Client Name* First Last Client is a*StudentStaff MemberFaculty MemberDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ReferralReferral Source*SelfFriendFacultyStudent SupportParentOtherReferral Name* First Last Referral Phone Number*Referral Email* Client's InformationClient Address* On Campus Off Campus Client Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Client Cell Phone Number*Client Email* Presenting Problem*Stress/Anxiety ManagementAdjustment to SchoolRelationshipsConflict ResolutionRegulating EmotionsGrief/LossAthletics/Academic PerformanceAlcohol/Substance UseOtherOtherDanger to Self?* Yes No Danger to Others?* Yes No Get help from individuals or agencies specializing in crisis intervention and suicide prevention. Take action. Remove means. If you are in crisis, find someone to be with you. If referring, do not leave a person in crisis alone: Call Student Development On Call 423.483.8391 Consult with Milligan Counseling Center Director 423.461.8500 Call 988 / Frontier Health Crisis Response and Suicide Hotline 877.928.9062 Appointment Availability(Choose up to 3 available times.)Mondays 8:30 a.m. 9:30 a.m. 10:30 a.m. 11:30 a.m. 12:30 p.m. 1:30 p.m. 2:30 p.m. 3:30 p.m. Tuesdays 8:30 a.m. 9:30 a.m 10:30 a.m. 11:30 a.m. 12:30 p.m. 1:30 p.m. 2:30 p.m. 3:30 p.m. Wednesdays 8:30 a.m. 9:30 a.m. 10:30 a.m. 11:30 a.m. 12:30 p.m. 1:30 p.m. 2:30 p.m. 3:30 p.m. Thursdays 8:30 a.m. 9:30 a.m. 10:30 a.m. 11:30 a.m. 12:30 p.m. 1:30 p.m. 2:30 p.m. 3:30 p.m. This field is hidden when viewing the formFridays 9 a.m. 10 a.m. 11 a.m. 12 p.m. 1 p.m. How would you prefer to meet?* In-person at the Counseling Center Zoom Telehealth Are you a Milligan Athlete?* Yes No Team*You will be emailed within 2 business days with scheduled intake appointment with one of our Milligan Counseling Center counselors.
