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Request for Services
Must be your @student.nmt.edu email
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Email *
Where did you hear about services at the Counseling Center? *
Name *
Preferred Name *
#900 *
Phone Number *
Please provide an emergency contact including name and number  *
Currently Enrolled at NMT? *
Required
How many hours are you enrolled? *
Date of Birth *
MM
/
DD
/
YYYY
Gender (for statistical purposes only) *
Sexual Identity (for statistical purposes only) *
Preferred Pronouns *
Required
Year in School *
Ethnicity *
Are you an International student?  *
Martial Status *
Current Address (Not a PO Box) (Can be Dorm) *
Permanent Address  *
In the past two weeks, have you used artificial intelligence (AI) tools, (e.g.,ChatGPT, Replika, etc.) in the following ways? Please check all that apply.  *
Required
Has your use of Artificial Intelligence tools created any problems for you? *
Are you aware of our FREE online resource for counseling called UWill?  *
Are you interested in virtual/online counseling sessions?  *
If you are not interested in online sessions, why not? *
What you want to address with the Counseling Center? (Do not give a diagnosis - be specific about symptoms, i.e. loss of appetite, increased stress etc.) *
Please indicate the general area of concern for your request
Column 1
Anxiety
Depression
Academic Stress
Relationship Issues
Family Conflict
Alcohol and/or Drug Use
Sleep Disturbance
Adjusting to College
Communication Problems
Trauma
Anger
Sexual Assault
Sexuality
Grief
Eating Disorder
Social Withdrawal
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