Home / Register Counseling Registration You don’t have JavaScript enabled. Please enable JavaScript in your browser settings and try link again. BU Student Counseling Registration Form * = mandatory field First Name: * Last Name: * Gender: Please select Male Female Other DOB: * Email: * Phone: * Current Address Street: * City: * State: * Please Select: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: * Graduation Date: Who referred you to us?: Self Student Health Services Behavioral Medicine Coach/Athletic Trainer Friend Other: If referred by other, who?: 1. Please select the option below that best reflects the PRIMARY reason for your visit so that we can schedule you with the appropriate provider. You may select additional reasons for your visit in the next section: * Healthy meal planning Concern about weight gain in college Healthy weight loss Sports nutrition Stress over/undereating Emotional over/undereating Social over/undereating Dining hall over/undereating Hunger management Unhealthy weight control practices Eating disorder (Check all that apply) Anorexia Nervosa Bulimia Nervosa Binge eating disorder Other Eating Disorder Food allergies or intolerances (Check all that apply) Wheat Milk Peanuts Tree nuts Eggs Shellfish Soy Fish Lactose intolerance Gluten intolerance FODMAPs Other: If other allegy or intolerance, please describe: Gastrointestinal disorder (Check all that apply) IBS Crohn’s Disease Ulcerative Colitis GERD Celiac Disease Other: If other gastrointestinal disorder, please describe: High blood pressure High cholesterol Diabetes/Pre-diabetes Vegetarian/vegan Iron-deficiency anemia Polycystic ovary syndrome Bariatric surgery Other: If other primary reason for visit, please describe: 2. Please select any secondary reason(s) for your appointment (check all that apply): * Healthy meal planning Concern about weight gain in college Healthy weight loss Sports nutrition Stress over/undereating Emotional over/undereating Social over/undereating Dining hall over/undereating Hunger management Unhealthy weight control practices Eating disorder (Check all that apply) Anorexia Nervosa Bulimia Nervosa Binge eating disorder Other Eating Disorder Food allergies or intolerances (Check all that apply) Wheat Milk Peanuts Tree nuts Eggs Shellfish Soy Fish Lactose intolerance Gluten intolerance FODMAPs Other: If other allegy or intolerance, please describe: Gastrointestinal disorder (Check all that apply) IBS Crohn’s Disease Ulcerative Colitis GERD Celiac Disease Other: If other gastrointestinal disorder, please describe: High blood pressure High cholesterol Diabetes/Pre-diabetes Vegetarian/vegan Iron-deficiency anemia Polycystic ovary syndrome Bariatric surgery Other: If other reason for visit, please describe: No secondary reason Additional information you would like to share: Availability Please provide your general availability 8am-5pm Monday through Friday using the checkboxes below. Please use the text boxes to indicate times of day you are generally available for any days you select. We will use this availability to schedule you for the next available appointment. Appointments are scheduled as soon as we are able. Wait times vary depending on provider availability. We will send you a confirmation email with the date and time of your scheduled appointment. Monday: If checked, enter the times you are available between 8am-5pm: Tuesday: If checked, enter the times you are available between 8am-5pm: Wednesday: If checked, enter the times you are available between 8am-5pm: Thursday: If checked, enter the times you are available between 8am-5pm: Friday: If checked, enter the times you are available between 8am-5pm:
