Wellness Coaching Intake Form

Peer Health Educators are available to provide support and guidance to all Skidmore students.  PHE's are not therapists or psychologists and services may not be right for all students.  If you believe that depression, anxiety, or other mental health disorders may be a factor for you, please visit the Skidmore Counseling Center. 

The questions on this intake form will provide us with information about your reasons for seeking out a one-on-one conversation with a PHE as well as a preliminary sense of how suitable this service is given your needs.  After you submit your form you will be contacted by email within 2 business days regarding next steps.

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* 1. What is your name?

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* 2. What is your Skidmore email address?

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* 3. What are your pronouns?

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* 4. What is your class year?

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* 5. In order for us to best match you with a Peer Health Educator, please provide some additional information about what topics you would like to discuss.  Please check all that apply.

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* 6. Please tell us a bit about why you want to focus on the topics that you selected.

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* 7. Please indicate your general availability below.  Your coach will be in touch to offer you time options that fit your preferences.

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday 
Morning (before 10am)
Late Morning (10-12)
Early afternoon (12-2pm)
Afternoon (2pm - 5pm)
Evening (5pm - 8pm)

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* 8. If you have a preference for a specific PHE, please provide the name of the PHE who you would like to work with.  Similarly, if there is a PHE who you would prefer not to be matched with, please share that information here.

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* 9. Would you like to be connected with a PHE who shares specific identities that you hold (ex/ class year, major, race, sexual orientation, gender identity, religion, etc)?  If yes, please share information that will be helpful to us in matching you with a Peer Health Educator.

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* 10. Is there any additional information that you would like to share?

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