Counseling Appointment Request

Appointment requests are for current KC students only.

Only enrolled KC students may request an appointment. Parents, professors, or other concerned parties should direct the STUDENT to this form. Please note that the form contents are confidential and go only to the counselor.

Are you a current KC student?(Required)

Are you a dual credit student currently enrolled in high school?(Required)

Are you 18 years of age or older?(Required)

Please note that the KC Counseling Office requires parental consent for anyone under 18 years of age.

Student's Name(Required)

First Last

KC ID#(Required)

KC Email Address(Required)

Please note that a KC email address is required to schedule an appointment.

Phone Number(Required)

Can you receive text messages at this number?(Required)

What is your college major?

Were you referred by anyone? If so, who referred you?

If you were not referred by a specific person, where did you hear about counseling services?

I would prefer my counseling session be:

Give a brief explanation of why you are seeking mental health counseling services.(Required)

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Counseling Appointment Request

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