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Counseling Services Request Form

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 staff member based on your response.

  • If you are off campus and in immediate danger, please call 911.
  • If you are on campus and experiencing a mental health crisis, please call MSOE Public Safety at 414-277-7159.

* = required field

Full Legal Name *
Preferred Name *
Phone Number *
Student Status *
Have you been diagnosed with a mental health condition? *
Have you been, or are you currently, under the care of a professional outside of MSOE for a mental health concern? *
Do you have a history of any of the following? Check all that apply. *
If you checked yes to any of the above question, when was the most recent? *
Symptoms/Concerns You Have (check all that apply) *

A staff member will reach out to you to find out more information and discuss next steps to support you by the end of the next business day.

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