BASICS student registration
Please complete and submit the pre-registration information below. Additionally you may submit payment using this form or pay later by phone or at Connections Counseling main clinic. After pre-registration, you will be contacted (initially by email, also by phone if necessary) to schedule your first individual session.
Mobile phone number
Home or other phone
Date of birth
BASICS completion deadline
Year in school
Campus address street
Campus address city
Campus address zip code
Have you completed CHOICES about alcohol group previously?
NO - referred directly to individual BASICS
YES - completed CHOICES at Connections
YES - completed CHOICES at Tellurian
Was marijuana also involved in this incident?
Dean of Students
Madison Police Dept
UW Police Dept
Other referral source
Name of referring individual
Referring individual email address
Ethnicity self-identification (voluntary)
Hispanic or Latino
White (Not Hispanic or Latino)
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Two or More Races listed above
Ethnicity not self-identified
Payment must be made before first session. Provide your VISA or MASTERCARD information to charge session cost of $125. Following registration and payment you will be contacted by Connections Counseling to schedule your first individual BASICS session. First contact will be by email. Payment may also be made by telephone (608-233-2100 x-0 Mon-Thur 9 am to 7 pm and Friday until 3 pm) or in person at Connections Counseling LLC, 5005 University Ave, Ste 100, Madison 53705.
Credit Card Type
Credit card expiration month
Credit card expiration year
CCV code on back of card
Billing name if not in your name
Billing zip code if not your campus address
Any addition information we should know? Include schedule preference (day of week, time of day)?
A copy of your responses will be emailed to the address you provided.
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