Conflict Resolution Intake Form This form is only for those who already have an appointment scheduled.If you'd like to be scheduled for an appointment, please fill out the following form: https://resolutioncenter.colostate.edu/request-an-appointment/1. Name* First Last Preferred Name Pronouns CSU ID # Email* Phone*What best describes your role at CSU? (check all that apply)* Student Faculty/Instructor Staff Other Please specify: What year are you in school? First Year Sophmore Junior Senior Graduate Student Non-Degree Seeking Which of the following are you enrolled in? On-campus degree program/classes that would be offered in-person under normal circumstances CSU Online degree/certificate program Not sure Other Are you a first generation college student? Yes No Are you a veteran? Yes No Which of the following do you identify with? Please check all that apply. Asian Black, Afro-Caribbean, or African American Latin@, Hispanic, or Spanish origin Native American or Alaskan Native Native Hawaiian or other Pacific Islander Middle Eastern or North African White Multi-Racial Self-Identify Prefer not to disclose Self-identify: What type of situation are you seeking assistance with? (check all that apply)* Academic Misconduct Appeals Accommodations/Accessibility Bias/Discrimination Concerning/Disruptive behavior Course content/Structure Conduct Case Conflict Dynamics Profile Covid-19 Criminal citation CSU Policies/Procedures CSU staff Degree progress/requirements Employment/Supervision Grading/Evaluation Graduate Advisor/PI Interpersonal violence Roommate(s)/Living situation Organization/Team/Club Conflict Personal relationship Professor/Instructor Restorative Justice Self-Improvement/Skill-building Other Brief description of the situation:*How did you find out about Conflict Resolution?* Academic Advisor Ads on campus Another student Case Management Court CSU Staff Member Health Network Ombuds Presentation/Event Professor/Instructor Student Conduct Student Disability Center Social Media SRC Website Student Legal Services Tell Someone University Housing Web Search/Google Other Type of Meeting:* In-person (We're located at 501 W. Lake Street, Suite A) Phone call (staff will call you at the number provided) Video call (via Microsoft Teams) Whom is your appointment scheduled with? Ashlyn Friend Hillary Condit Kayla Schlenz Maggie Burks Not sure Would you like translation services? Yes No For translation services, please select one of the following languages:N/AArabicBosnianBrazilian PortugueseCambodianCantoneseCroatianFarsiFrenchGermanHaitian CreoleHindiHmongJapaneseKoreanLaoMandarinPunjabiRomanianRussianSerbianSomaliSpanishThaiTagalogVietnameseDo you require a disability related accommodation for this meeting? Yes No Please specify: CONFIDENTIALITY:*Information shared with Conflict Resolution Services will be kept confidential to the extent permitted by law. EXCEPTIONS: Staff are required to report any and all information related to incidents of sexual misconduct and/or interpersonal violence to the Office of Title IX Programs and Gender Equity. Allegations of child abuse or credible threats of future harm to any person shall not be held confidential and may be revealed as appropriate by staff. I understand and agree to these conditions. EmailThis field is for validation purposes and should be left unchanged.