Gallaudet University- Counseling and Psychological Services
Client Information Form
WARNING: If this is an emergency, contact DPS 202-651-5555 (voice or text), or dps@gallaudet.edu (email) or call 911 immediately.
Please enter your personal information below.
First Name:
*
Last Name:
*
Preferred Name:
Preferred Pronouns:
Date of birth
*
Student ID:
*
Local/VP Phone:
OK to Phone?
Yes
No
Cell Phone:
OK to Phone?
Yes
No
Home Phone:
OK to Text?
Yes
No
Email:
Note: unencrypted email is not a secure form of communication. There is some risk that individually identifiable health information that may be contained in such email could be misdirected, disclosed to or intercepted by unauthorized third parties. By clicking Yes, you indicate that you understand the risk.
*
Yes
No
Local Address
OK to contact at Local address?
Yes
No
Home Address
OK to contact at Home address?
Yes
No
Second Email Address
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