ÌðÐÄÖ±²¥

Request for Information

In the case of a life-threatening emergency, call University Police at 815-836-5911 if on campus and 911 if off campus.

*First Name: 

*Last Name: 

*Student ID#: 

*Date of Birth:  
 (MM/DD/YYYY) 
*Phone: 

*Lewis Email: 

*Student Level: 
 Undergraduate
 Graduate

*Learning location: 
 On-campus, in person courses
 Online or hybrid courses

*Student Type: 
 Off-campus commuting student (please provide current address)
 On-campus residential student (indicate specific residence hall)

If commuting student, provide current location with Street/City/State/Country

Street:	City:
State:	Country:

If resident student, please provide residence hall:

Please mark all times you are available to meet:

Monday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Tuesday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Wednesday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Thursday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

Friday: 
 9am
 10am
 11am
 12pm
 1pm
 2pm
 3pm
 4pm

*I am interested in scheduling:
 A brief Phone Consultation to schedule services (15 min)
 In person or video Care Connect Meeting for service recommendations and resources (30 min)

For Care Connect, I prefer meeting (select 1):
 In Person
 Telehealth Video

*Wellness Room Scheduling:
 Verilux HappyLight Therapy - improves mood safely and reduces seasonal depressive symptoms. (30 mins)
 Massage/Relaxation Chair (30 mins)

For scheduling any additional on-campus health services, call Center 815-836-5455 to schedule. Information on scope and services available here.

*If telehealth request, is our 24/7 virtual telehealth partner - student wellbeing care, from anywhere at any time. On-demand TalkNow for emotional support, MedicalNow health consult by phone or video, scheduled health and counseling services and self-help resources are available. Use your Lewis U email to log in at or download the TimelyCare app. More information about TimelyCare here:

*I plan to register and connect with TimelyCare:
 Yes
 No

*I would still like information and follow-up from the Student Wellness Center:
 Yes
 No

I would like to be contacted to learn about counseling group opportunities.:
 Yes
 No

*Group counseling opportunities are updated each semester. If you have questions, please let us know when we contact you or call the Center at 815-836-5455.

*I give permission for Counseling Services to use my email for communication regarding this information request:
 Yes
 No

*I give permission for Counseling Services to utilize my cell phone for communication regarding this information request:
 Yes
 No

Emergency Name: 

Emergency Relation: 

Emergency Phone: 

For Urgent Care Meeting, please call the Center at (815) 836-5455 Monday – Friday 8:30 a.m. – 4:30 p.m.

Security Password (Please type the word ):

For emergency support (365 days per year - 24/7)

ÌðÐÄÖ±²¥ Police Department:
Emergency: 815-836-5911 (On Campus) 911 (Off-Campus)
Non-emergency: 815-836-5222

Call 988 for 24/7 free, confidential help for mental health crises and support for persons in emotional distress.

Live chat is available at or text HOME to 741741

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