Fort Lewis College Counseling Center Client Form

Fort Lewis College
Student Counseling Center
Client Data Form
Warning: If this is an emergency, please contact 911 or from a campus phone, 9-911. Please know that the forms you complete are not monitored in real time and will only be viewed by office personnel during regular business hours.

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Please enter your personal information below.
Note that any required fields are indicated by * (asterisk)
*First Name:	*
Middle Initial:
*Last Name:	*
Preferred Name:
Pronouns:
*Date of birth	* (mm/dd/yyyy format)* Invalid date.* Invalid date.
*Student ID:	*
*Cell Phone:	* OK to phone?YesNo
*Emergency Contact Phone:	*
*Text messaging: OK to send text message for appointment reminders?	*
*Email:	* OK to email?YesNo
*Local Physical Address:	*
*OK to contact at Local Physical Address:	YesNo*
*Emergency Contact Name & Address:	*

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