Request for Information

In the case of a life-threatening emergency, call University Police at 815-836-5911 if on campus and 911 if off campus.

*First Name: 

*Last Name: 

*Student ID#: 

*Date of Birth:  
 (MM/DD/YYYY) 
*Phone: 

*Lewis Email: 

*Student Level: 
 Undergraduate
 Graduate

*Learning location: 
 On-campus, in person courses
 Online or hybrid courses

*Student Type: 
 Off-campus commuting student (please provide current address)
 On-campus residential student (indicate specific residence hall)

If commuting student, provide current location with Street/City/State/Country
Street:  
City: 
State:  
Country: 
If resident student, please provide residence hall:

Please mark all times you are available to meet:
Monday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Tuesday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Wednesday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Thursday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Friday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm



*I am interested in:
  Initial Meeting to discuss counseling services and care options available. (1 hr)
 Single Session Consultation for resources, referrals (1-2 sessions for 1hr)
 Verilux HappyLight Therapy - improves mood safely and reduces seasonal depressive symptoms. (30 mins)
 Massage/Relaxation Chair (30 mins)

For scheduling any additional on-campus health services, call Center 815-836-5455 to schedule. Information on scope and services available here. https://lewisu.edu/studentservices/studentwellnesscenter/healthservices/index.htm

*I prefer meeting:
 In Person
 Telehealth Video

*If telehealth request, is our 24/7 virtual telehealth partner - student wellbeing care, from anywhere at any time. On-demand TalkNow for emotional support, MedicalNow health consult by phone or video, scheduled health and counseling services and self-help resources are available. Use your Lewis U email to log in at www.timelycare.com/lewisu or download the TimelyCare app. More information about TimelyCare here: https://lewisu.edu/studentservices/studentwellnesscenter/timelycare.htm

*I plan to register and connect with TimelyCare:
 Yes
 No

*I would still like information and follow-up from the Student Wellness Center:
 Yes
 No

I would like to be contacted to learn about counseling group opportunities.:
 Yes
 No

*Group counseling opportunities are updated each semester. If you have questions, please let us know when we contact you or call the Center at 815-836-5455.

*I give permission for Counseling Services to use my email for communication regarding this information request:
 Yes
 No

*I give permission for Counseling Services to utilize my cell phone for communication regarding this information request:
 Yes
 No

For Urgent Care Meeting, please call the Center at (815) 836-5455 Monday – Friday 8:30 a.m. – 4:30 p.m.

Security Password (Please type the word ):

For emergency support (365 days per year - 24/7)

Lewis University Police Department:
Emergency: 815-836-5911 (On Campus) 911 (Off-Campus)
Non-emergency: 815-836-5222

988 logo

Call 988 for 24/7 free, confidential help for mental health crises and support for persons in emotional distress.

Live chat is available at 988lifeline.org/chat or text HOME to 741741