Lipscomb UCC Consultation Request Form 2023-2024
PLEASE FILL OUT THE ENTIRE FORM. All information given will be kept strictly confidential. Please remember UCC services are for CURRENT Lipscomb students. 
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Date Completing Form *
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Full Name (First, Middle, Last) *
Date of Birth *
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L# *
Lipscomb E-mail *
Phone Number *
Dorm or Local Address *
Emergency Contact Name and Phone Number *
Race and/or Ethnicity *
Gender and Pronouns *
Sexual Orientation *
Marital Status *
Religious Affiliation  *
Major *
Are you enrolled as a current Lipscomb student? *
Classification 
(i.e. Freshman, sophomore, junior, senior, grad student)
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If you are a student, when do you intend to graduate? (If this question does not apply to you, please type "n/a")
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Are you employed by Lipscomb? *
Please list your hours of *availability* throughout the week. DO NOT LIST CLASS SCHEDULE. Note that we are open Monday-Friday from 8 AM to 5 PM with sessions starting on the hour. After the consultation, if you are scheduled for regularly occurring counseling appointments, they will be scheduled weekly for the same day and time. Please list ALL available times throughout the week.
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If applicable, who referred you to the UCC?
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