Schedule an Appointment

Once you have scheduled an appointment:

Bring a completed Emergency Fund Request and bills, if applicable
Be sure to bring all pertinent documents to the appointment
Bring a doctor's note or obituary / death certificate, if applicable

Items marked with * are required fields. Please mark fields that aren't applicable with n/a.

If you have previously been seen by one of our staff on this EXACT issue, please complete only the UTEID, Name, Date of Birth and updated problem description. Please complete the remaining blanks with N/A as long as none of your information has changed.

*UTEID:

*Last Name:

*First Name:

*Middle Name:

*Date of Birth: (mm/dd/yyyy)

Classification:

Major:

*Austin Street Address:

*Austin Address Zip Code:

*Home Phone Number:

*Work Phone Number:

*Permanent Phone Number:

Cell Phone Number:

*Email Address:

*Permanent Street Address:

*Permanent Address City:

*Permanent Address State:

*Permanent Zip Code:

*Please indicate if we should not contact you at any of the above locations:
(if not applicable, enter "n/a")

*Citizenship:

Ethnicity:

How did you learn about our service? If you were referred by UT faculty/staff, please give us their name (optional).

*What concern(s) bring you to SES? (2000 characters or less):

*SES is occasionally contacted by parents or guardians regarding client matters. Do you authorize us to discuss this matter with your parents or guardians? (You may modify this consent at any time by notifying us in writing.)
Yes No
If yes, please list the names of parents or guardians with whom we may discuss this matter:

*What assistance are you asking from from Student Emergency Services? (2000 characters or less)

Please List 3 Preferred Appointment Dates At Least 48 Hours From Now

* Appointment Date, First Choice:
Month:
Day:
Time:

* Appointment Date, Second Choice:
Month:
Day:
Time:

* Appointment Date, Third Choice:
Month:
Day:
Time:

I understand that email correspondence may not be confidential. If I choose to correspond with this office via email, I do so at my own risk, and I agree that this office will not be responsible for any unauthorized interception of such email message(s) by third parties. I also waive any objection to any potential breach of my confidentiality or privacy that I may have if the office responds to my email.

I have read and understand the provided policies and procedures of the Student Emergency Services office.

*Acknowledgement Initials: