Counseling Services Request Form
Counseling Services Request Form
Welcome to IVC! We will respond to your request within 1-2 business days.
Name
Name
*
First
Last
Email
*
Phone
Phone
*
-
###
-
###
####
Student G# (ID Number)
*
I need to meet with a counselor for the following (select all that apply):
*
I need to meet with a counselor for the following (select all that apply):
Course Recommendations ( I would like to know what classes to take)
Exploring/Choosing/Changing a Career Pathway (I need help selecting/changing a major)
Counseling Educational Plan (I would like a guided plan of what classes to take at IVC)
Graduation/Transfer Requirements
Academic/Degree Petitions (I need to petition to retake a class, reinstate financial aid, etc.)
Help with English and Math Placement (I need helping choosing what English or Math courses to take.)
Other, please provide an example:
Other, please provide an example:
Other Services
Other Services
I need help applying to IVC
I need help to select classes at IVC
I need help with Financial Aid
I want to sign up for Tutoring
Other, please provide an example:
Other, please provide an example:
Basic Needs
Basic Needs
I am at risk of losing housing (i.e. being kicked out, evicted, couch surfing)
I do not have access to food
I would like to speak with a mental health counselor
I need help with child care
I need help paying for books - I do not receive financial aid
I need help with a computer or wifi device
I need help with transportation to get to IVC
Other
Other
Appoinment Modality:
*
Appoinment Modality:
I would like to see a counselor in person
I would like to see a counselor online via zoom
Appointment Preferences: I prefer to have an appointment scheduled on:
*
Appointment Preferences: I prefer to have an appointment scheduled on:
Monday
Tuesday
Wednesday
Thursday
Friday
Appointment Preferences: I prefer to have an appointment scheduled in the:
*
Appointment Preferences: I prefer to have an appointment scheduled in the:
Morning (8AM - 11AM)
Afternoon (12PM-4PM)
Evening (4PM-7PM)
Are you a part of any of the following programs:
Are you a part of any of the following programs:
EOPS/CARE
SSS - Student Support Services TRIO
DSPS
CalWORKS
I am a high school student
Other
Other
Is there anything else you would like to share with us and/or are there other services we can help with?
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