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My USC Lancaster

Counseling Services Intake Form

(All counseling files are held in strict confidence)

*Required fields

0/0/0000

Gender Identity *
Race/Ethnicity *

(Street, City, State, Zip)

(000) 000-0000

May we leave a message? *

johndoe@email.sc.edu

May we send a message? *

(000) 000-0000

(000) 000-0000

Referral *
Reason for your visit (Please check all that apply): *
Have you been treated for mental health issues? *

(Month/Year)

The University of South Carolina Lancaster Counseling Services is provided free of charge to active students. Counseling records are NOT a part of your academic records and are held in strict confidence. Please review my Professional Disclosure Statement, Informed Consent, and Notice of Privacy Policy and sign those forms to bring in to your first appointment. If you have any questions, please call call the Counseling Services at 803-313-7162 or email marytlee@mailbox.sc.edu.

Please type your full name above as your electronic signature


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