Mesa Online Counseling Appointment Request Form

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**DO NOT COMPLETE THIS FORM IF YOU WOULD LIKE AN IN-PERSON COUNSELING APPOINTMENT. THIS FORM IS INTENDED FOR STUDENTS REQUESTING ONLINE COUNSELING APPOINTMENTS THROUGH ZOOM CONFERENCING.**

Email *

Today's Date *

YYYY

Last Name, First Name *

MySDCCD 10-digit User ID *

Email Address *

Phone Number (include area code) *

Degree Objective *

Obtain an associate degree without transfer

Obtain an associate degree and transfer to a 4-year institution

Transfer to a 4-year institution without an associate degree

Obtain a certificate without transfer

Undecided on goal

Other:

Major Objective *

Do you have a Career Plan? *

Yes

Required

If you do have a Career Plan, please describe it.

Reason for Requesting an Online Appointment *

Each of the following criteria must be met and checked before an online counseling appointment can be scheduled: *

Completed the Placement Assistant or a Math and English Class

Official transcripts of all colleges attended on file

Official transcripts must be evaluated for course equivalency.

Completed one semester of college coursework.

Enrolled in at least one class for the current semester

Required

If you do not meet one or more of the above eligibility criteria, please provide an explanation as to why you do not meet the criteria.

By submitting this form, I agree to the following: *

I have read and confirm the Statement of Consent. I would like to request an online counseling appointment.

I have read and am not ready to confirm the Statement of Consent. An online appointment will not be made, and I will explore other services for my questions.

Send me a copy of my responses.

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