Request an appointment with FSAP You must have JavaScript enabled to use this form. Indicates required field Are you an active CU Boulder employee? Yes No If no, you may not be eligible for FSAP services. If you are a student, student employee or graduate student, please contact Counseling and Psychiatric Services (CAPS). Will you be present in Colorado at the time of your appointment? Yes No State law requires all counseling clients to be physically present in the state of Colorado at the time of service. If you will not be in Colorado at the time of your appointment, please indicate when you will be or wait to submit this form until you’re in Colorado. Legal first and last name Please include your preferred name (ex. Ralph “Ralphie” the Buffalo) if it differs from your legal name. Pronunciation Pronouns Learn more at: https://www.colorado.edu/cisc/pride-office/lgbtq-resources/pronouns Identikey Your IdentiKey helps us verify your identity. If you don’t know your IdentiKey, put ”Unsure”. Department name Your position title CU email address Preferred email If you would like to receive communications from FSAP at an email not affiliated with CU, please list it here. If you’d like to be contacted through your CU Boulder email, leave this area blank. Preferred appointment type - Select -In PersonVirtual (Telehealth)No Preference You and your provider may change this for future appointments. What are you looking for in counseling? - Select -Individual CounselingRelationship or Family CounselingOther Have you used FSAP counseling before? I have never used FSAP counseling I am returning and would like to see my past provider I am returning and would like to work with a new provider I am returning and do not have a provider preference Your past provider's name What would you like to discuss? Please tell us in a few short sentences about what you’d like to discuss with your FSAP counselor. Contact agreement Yes No We will contact you by email unless otherwise instructed. If you do not respond after up to two attempts, you will need to complete this form again. I understand and accept Additional information Is there any additional information you’d like for us to know?
