Interested in Counseling Services

**If you are having thoughts ending your life, thoughts of self harm, and/or thoughts of harming someone else, please call our office at 217-581-3413. If it is after hours, or if our office is unavailable, call 1-866-567-2400.**

Today's Date: Today's Date: / MM / DD YYYY
Name: Name: * First Last
Are you enrolled in classes for the current semester? *

Are you enrolled in classes for the current semester? yes no
E# *
EIU Address:
Cell Phone: Cell Phone: * - ### - ### ####
If we cannot reach you by phone, can we contact you via email?

If we cannot reach you by phone, can we contact you via email? YES NO
Panther Email:
NOTE: The Counseling Clinic phone number will show as "block" or "restricted" when receiving incoming calls
When is the best time to reach you?
Emergency Contact Information

Name of Emergency Contact:
Emergency Contact Phone Number:
This is my:

This is my: Parent/Guardian Spouse Other Other
Are you currently having thoughts to harm yourself or others, including suicidal ideation? *

Are you currently having thoughts to harm yourself or others, including suicidal ideation? Yes No

If you answer Yes to this Question, please call the 24 hour crisis line at
1-866-567-2400
In the past, have you ever acted on thoughts of suicide or self harm? *

In the past, have you ever acted on thoughts of suicide or self harm? yes no
Within the last few months, have you experienced a trauma or an assault? *

Within the last few months, have you experienced a trauma or an assault? Yes No
In the past few months, have experienced a loss or the death or someone close to you?

In the past few months, have experienced a loss or the death or someone close to you? Yes No

Interested in Counseling Services

Interested in Counseling Services

NOTE: The Counseling Clinic phone number will show as "block" or "restricted" when receiving incoming calls