Health Promotion Consultation Request Form

One-on-one consultations at the HERC

EIU students have the opportunity to meet with one of our staff on a variety of health related topics. Many of the sessions are strictly educational and FREE. Some of the topics include the following but are not limited to this list:

Sleep
Sexual Health
Alcohol & Other Drugs
Peer Education Opportunities
And many more!

Please note: to make an appointment with a Licensed Clinical Counselor you must contact the Counseling Clinic at 217-581-3413.

Name Name * First Last
Phone Phone - ### - ### ####
Panther Email *
What is the best way to contact you? *

What is the best way to contact you? Phone Email
Please select the topic(s) you would like to focus on in your one-on-one consultation. *

Please select the topic(s) you would like to focus on in your one-on-one consultation. Alcohol Other Drug Sleep Sexual Health Tobacco Other, please specify below
If your topic was not listed above, please identify what you would like to discuss.
Please identify a possible date you would like to meet. We will do the best to accommodate, if we are not available during this day we will work with you to schedule a day and time. Please identify a possible date you would like to meet. We will do the best to accommodate, if we are not available during this day we will work with you to schedule a day and time. / MM / DD YYYY
Please provide any information that will help us prepare for your consultation.