MDC Appointment Request Form  

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Personal info (* = required)

Additional information

Free Periods
Check all that apply Mon Tue Wed Thu Fri
1st Period
2nd Period
3rd Period
4th Period
5th Period
6th Period
Areas of Concern

Place a check in the box adjacent to any area of concern.

  1. Abuse, current (physical, sexual, emotional)
  2. Abuse, past (physical, sexual, emotional)
  3. Academic performance/study skills
  4. Adjustment to the Academy
  5. Alcohol/drugs
  6. Anxiety
  7. Assertiveness
  8. Body Image
  9. Concern about a friend
  10. Confusion about beliefs/values
  11. Decisions about career/major
  12. Depression
  13. Eating problem
  14. Family problems
  15. Finances
  16. Grief/loss/illness of other
  17. Harassment/discrimination
  18. Homesickness
  19. Irritability, anger, hostility
  1. Indecision about staying/resigning from USNA
  2. Making friends
  3. Medical/physical problems
  4. Parent divorce
  5. Procrastination/getting motivated
  6. Relationship with friends/peers
  7. Relationship with parents(s)
  8. relationship with romantic partner
  9. Religious/spiritual
  10. Roommate conflict
  11. Performance/conduct/honor problem
  12. Self-esteem/self-confidence
  13. Sexual assault/unwanted sex
  14. Sexuality concerns
  15. Sleeping problems
  16. Smoking cigarettes
  17. Stress Management
  18. Suicidal feelings/thoughts
  19. Test/speech/performance anxiety
Important Concerns

Please select your top concerns in order of importance with 1 being most important:


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