LPU Student Emmaus Road Inquiries
Students of Life Pacific University will use this form to submit a request for counseling services with Emmaus Road. Availability of therapist is not guaranteed, and you will be notified if a waitlist or other referrals are necessary.
First Name *
Your answer
Last Name *
Your answer
Birthdate (including year of birth) *
MM
/
DD
/
YYYY
Phone number *
Your answer
Provide your @lifepacific.edu email address as proof of LPU student status: *
Your answer
Select all options you are available weekly to see a therapist. A therapist will contact you to schedule a specific time. *
Morning (9am-12pm)
Afternoon (1pm to 4pm)
Evening (5pm-8pm)
Not available this day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Have you seen a therapist at ERCC before? *
If seeking couples counseling, you must provide your partner's name and email address:
Your answer
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