Counseling Services Evaluation Form

NC State University Counseling Center Appointment Cancellation Form

Please provide of all the following information:

First Name:
Last Name:
Student ID Number:
Do you wish to cancel your scheduled appointment?YesNo
Please provide the reason for cancelling your appointmentSchedule ConflictIllnessOut of TownNeed to be in ClassDon't wish to keep appointmentOther
Reason:
Do you wish to reschedule the appointment you are cancelling?YesNo
Please contact the Counseling Center during regular hours (8-5, M-F) at 515-2423 or come in to the center in order to reschedule your appointment. Okay
Time of Scheduled Appointment:

Date of Scheduled Appointment:

If you were scheduled to see a Psychiatrist: With whom was your appointment scheduled?Dr. Jackson ChiuDr. Lydia Miller-AndersonDr. Leslie MontanaDr. John WallaceOther:
Please type the person's name: