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Contraceptive Consultation Request Form

Do you have questions about contraception? Meet with a trained Peer Educator or Health AWAREness Staff member to learn more about your contraceptive options.

Contraceptive Consultations are designed to provide students with information on contraceptive methods and to refer students to campus/community medical providers so that they may obtain contraception.

Note: You do not receive a prescription for contraception by participating in a contraceptive consultation. In order to obtain or refill a prescription, you can make an appointment with Health Service by calling 724-357-2550.

All fields are required except where otherwise indicated.

Are you comfortable with a male consultant?
      
Which method are you most interested in learning about?

Check all that apply.

       

(optional)
 

Please indicate your availability






Contact Information

 

 


 


 

Upon completion of this form, you will receive a confirmation that your request has been sent. A request does not guarantee an appointment. A representative from the Health AWAREness office will contact you within 48 hours to finalize appointments. We reserve the right to refuse a request. Please contact the Health AWAREness Office with specific questions.

  • Health AWAREness
  • Suites on Maple East
    Suite G-59
    901 Maple Street
    Indiana, PA 15705
  • Phone: 724-357-4799
  • Fax: 724-357-4457
  • Office Hours
  • Monday through Friday
  • 8:00 a.m. – 12:00 p.m.
  • 1:00 p.m. – 4:30 p.m.