University of Maryland, College Park
Counseling Center
WARNING: If this is an emergency, call 911 immediately.
Please enter your personal information below.
First Name:
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Last Name(s):
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Preferred First Name Name:
Pronouns used:
Date of birth
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Student ID (Cell # if not a UMD student):
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Mobile Phone:
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OK to leave a message?
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Yes
No
Home Phone:
OK to leave a message?
Yes
No
Text messaging (first appointment notification only):
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Use Mobile phone
Use Home
Do not send text messages
Email:
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OK to email (necessary for appointment remiders and general communication)?
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Yes
No
Local Address
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OK to contact at Local address?
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Yes
No
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