Counseling Center at University of Maryland

Name:

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UID

*

E-mail address:

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Phone number:

*

I am requesting assistance in following areas:

(Please check ALL the applicable areas)

Motivation

Math Learning

Time Management

Class Note Taking/Listening

Reading

Review

Test Taking/Text Anxiety

Other

Source:(How were you referred?)

Self-Referred

Recommended by a Peer

Recommended by an Instructor

Recommended by Advisor

Referred by DSS Counselor

Other

Preferred Date (mm/dd/yy):

*

Preferred Time:

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Alternate Date (mm/dd/yy):

*

Alternate Time:

*

Comments:

Calendar of Events