HMSA Counselor Appointment Request/Sign-In

Please fill out the following referral form if:

-You would like to request a meeting with a counselor.
-You came into the counseling office for walk-in services.
-Would like a counselor to answer some questions.

This referral form is confidential.

A counselor will call you to the office, e-mail/send you a counselor meeting time and date or respond to your questions/concerns as soon as possible.

If this is urgent please go to the counseling office immediately.

If this is an emergency, please call 9-1-1.

National Suicide Hotline: 1 (800) 273-8255

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