Counseling Appointment Request

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

I certify that I am a currently enrolled student at Tyler Junior College*

YesNo

Which Semester:*

(Example: Spring 2020)

I am also currently enrolled in high school*

YesNo

Full Name:*

First NameLast Name

A#:*

TJC Email:*

Please note, a TJC email address is required to obtain appointment

Please use your TJC email address.

Major/Program:

Phone Number:*

Can you receive text messages at this number?*

YesNo

Referred by:

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

I would prefer my session to be:*

Online, utilizing video chat or zoom on my device from my own private locationIn-person, physical attendance to the waiting area and counselor's office

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

Appointment Options: Please check all times available*

	9am	10am	11am	1pm	2pm	3pm	None
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

or

None of the times listed above work for me

Upon submission of this form, please check the TJC email address provided for form receipt confirmation and a subsequent appointment offer. Appointments not accepted/confirmed within 48 hours of the offer will be automatically cancelled.