If you are interested in speaking with the Residence Counsellor, please complete the following form. Please note that every effort will be made to contact you by phone within 48 business hours to book an appointment. Same-day appointments are available on a first-come, first-serve basis on Wednesdays. Students can pick up the appointment time cards at the Residence Services Desk area. Disclaimer: If this matter is urgent, please call Campus Police at (416) 978-2222 or the Health and Counselling Centre at (416) 287-7065. If this an emergency do not complete this form, please call Campus Police at (416) 978-2222 or dial 911. Student Number * First Name * Last Name * Phone Number Email Address * Residence * - Select -AspenBirchCedarDogwoodElmFirGrey PineHickoryIronwoodJuniperKoaLarchMapleJoan Foley Issues of concern (please check all that apply) * Academics Anxiety & stress Bereavement Body image Depression Financial concerns Need a note or document (such as a VOI) Relationship issues Sexual assault Sexuality and gender Substance abuse Suicide / Self harm Other Please specify What are you hoping to accomplish in seeing the residence counsellor? (optional) Disclosure of Personal Information The Residence Counsellor provides counselling to current residents as an extension to the Health and Wellness Centre (HWC), thus any personal information collected will be stored in a shared medical record with the HWC. To review the HWC confidentiality policy, go to: www.utsc.utoronto.ca/hwc/confidentiality.