Bowling Green State University
Counseling Center
Confidential Student Information Form
Please enter your personal information below.
First Name:
*
Middle Name:
Last Name:
*
Chosen Name:
Preferred Pronouns:
Date of birth
*
Student ID:
*
Cell/Primary Phone:
*
OK to leave a message at this number?
*
Yes
No
Home Phone:
OK to leave a message at this number?
Yes
No
The BGSU Counseling Center uses text reminders to remind students of their upcoming appointments. If you consent to receive a text reminder for your appointment, please indicate which phone number we should use.
Use Cell/Primary
Use Home phone
Do not send text messages
BGSU Email:
*
OK to email?
*
Yes
No
Current (incl county) Address
*
OK to contact at Current (incl county) address?
*
Yes
No
Home Address
OK to contact at Home address?
Yes
No
Please provide a name and phone number for an emergency contact person.
We would call this person only if there is an immediate safety concern
and we're unable to reach you.
*
Next
Please wait while your browser submits your request…