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Community Wellness and Counseling Center Client Inquiry Form
* Indicates required question
Email
*
Your email
Legal Name
*
Your answer
Preferred Name
Your answer
Referred by:
Self
Housing Authority of Elizabeth (HACE)
Kean University Program
Other
Preferred Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Other
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Home Address
Your answer
Best Phone Number to Reach You
Your answer
Is it ok to leave a message at this number?
Yes
No
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Email Address
Your answer
Emergency Contact Information
Name
Contact Number
Relationship to Client
Your answer
Reason for Seeking Services
Please briefly describe your/ your client’s current needs or reasons for seeking counseling services
Your answer
A copy of your responses will be emailed to the address you provided.
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