Dallas Baptist University Counseling Center

Dallas Baptist University
Counseling Center
New Intake Form
WARNING: If this is an emergency call 911 immediately. If you are on campus call campus police at 214-333-5555.

Do not use the browser's 'Back' button in this application; doing so will result in loss of your entered data.

Please enter your personal information below.
Note that any required fields are indicated by * (asterisk)
*First Name:	*
Middle Name:
*Last Name:	*
*Date of birth	* (mm/dd/yyyy format)* Invalid date.* Invalid date.
*Student ID:	*

We're sorry but your browser 'Back Button' should not have been used.

Please click the 'Return to Menu' button below to return to the menu.

Please notify the front desk staff so they can delete your previous session if necessary.