Nutritional Analysis Consultation Request Form

One-on-one consultations at the HERC

EIU students have the opportunity to meet with one of our staff on a variety of health related topics. Many of the sessions are strictly educational and FREE. Some of the topics include the following but are not limited to this list:

Nutritional Analysis
Peer Education Opportunities
And many more!

Please note: to make an appointment with a Licensed Clinical Counselor you must contact the Counseling Clinic at 217-581-3413.

Name Name * First Last
Phone Phone - ### - ### ####
Panther Email *
What is the best way to contact you? *

What is the best way to contact you? Phone Email
Please select the topic(s) you would like to focus on in your one-on-one consultation. *

Please select the topic(s) you would like to focus on in your one-on-one consultation. Alcohol Other Drug Nutrition Financial Health Sleep Sexual Health Tobacco Other, please specify below
If your topic was not listed above, please identify what you would like to discuss.
Please identify a possible date you would like to meet. We will do the best to accommodate, if we are not available during this day we will work with you to schedule a day and time. Please identify a possible date you would like to meet. We will do the best to accommodate, if we are not available during this day we will work with you to schedule a day and time. / MM / DD YYYY
Please provide any information that will help us prepare for your consultation.