Schedule an Appointment

*UT EID:

*Last Name:

*First Name:

*Middle Name:

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

Classification: Select one... Freshman Sophomore Junior Senior Graduate Student

Major:

*Austin Street Address:

*Austin Address Zip Code:

*Home Phone Number:

*Work Phone Number:

*Permanent Phone Number:

Cell Phone Number:

*E-mail Address:

*Permanent Street Address:

*Permanent Address City:

*Permanent Address State:

*Permanent Address Zip Code:

*Please indicate if you prefer NOT to be contacted at any of the above locations:
(if not applicable, enter "n/a")

*Citizenship: Select one... United States Argentina Australia Brazil Canada Chile England France Germany Hong Kong India Indonesia Ireland Italy Japan Malaysia Mexico Nigeria China (P R China) Pakistan Russia Scotland South Africa South Korea Switzerland Taiwan Ukraine Venezuela Other

Ethnicity: Select one... Anglo American Asian American Hispanic American African American Other American International

How did you learn about Student Emergency Services? If you were referred by UT Austin faculty/staff, please provide their name (optional).

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

*Parents or guardians occasionally contact SES with questions about a particular client matter. Do you authorize us to discuss your case 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 your case:

*What assistance are you requesting from Student Emergency Services? (2,000 characters or fewer)

List 3 preferred appointment dates/times (MUST be at least 24 hours from now)

SES hours of office operation are Mon.-Fri. 8 a.m.-5 p.m. excluding school holidays and closures.

* Appointment Date, First Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

* Appointment Date, Second Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

* Appointment Date, Third Choice:
Month: Select One... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day:      Select One... 12345678910111213141516171819202122232425262728293031
Time:    Select One... AM PM

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

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

*Acknowledgement Initials: