Javascript is required to load this page.
Page Loaded
First and Last Name
Please enter your 855 number:
Are you currently receiving health or counseling services from the Counseling, Health & Wellness Center? If so, what is the name of the clinician you last saw?
No
Yes
Preferred method of being contacted:
Student email address
Cell phone call
Are you currently living on campus? If so, what is your dorm name and room number.
No
Yes
Are you currently receiving medical or counseling services for smoking cessation?
No
Yes
What types of services are you presently interested in for smoking cessation. Please select all that apply.
Assessment to understand current use of tobacco
Counseling services
Nicotine Replacement Therapy (NRT gum, patch, etc)
Medical evaluation
Group services
How did you hear about our services?
CHWC Website
CHWC staff member (medical staff, counselor)
Faculty/Staff at WPU
Friend
Other
Powered by Qualtrics