February 5, 2016 Shaun GeisertRequest an AppointmentIf you are a distance learner, we can provide meetings via phone or video conferencing.Name* First Last CSU ID#:*Preferred Name:PronounsEmail* Phone*Preferred LanguageWe offer in-house Conflict Resolution Services in English and Spanish. If you prefer another language translated via Language Link, please select the "Other" option and choose "Translation Language" available. English Spanish OtherTranslation LanguageN/AArabicBosnianBrazilian PortugueseCambodianCantoneseCroatianFarsiFrenchGermanHaitian CreoleHindiHmongJapaneseKoreanLaoMandarinPunjabiRomanianRussianSerbianSomaliSpanishThaiTagalogVietnamesePlease indicate which of the following you most identify with: Native American or Alaskan Native Black or African American Asian/Pacific Islander Hispanic or Latin@ Middle Eastern/North African/Arab Multi-Racial White Self-IdentifyAre you a part-time student (less than 12 credits)?*YesNoAre you a CSU Online Student?*YesNoIf you are enrolled in CSU Online, which of the following best describes your enrollment?DegreeNon-DegreeAre You a Faculty/Staff Member?*YesNoType of Conflict* Academic matters Academic misconduct Classroom conflict Conduct Appeal Discrimination Faculty/student conflict Other (describe at right) Grade dispute Personal safety Roommate conflict Student organization conflict University policies and procedures Workplace disputeOther ConflictBrief description (and desired outcome) of conflict:*How long has the conflict been going on:*Less than a weekA weekLess than a monthBetween one and five monthsBetween six months and a yearMore than a yearOther Prior Action(s), if applicable:How did you find out about Conflict Resolution? Advisor Brochure Counseling Services CSU staff/faculty Facebook/Instagram Friend Other (describe at right) Print/LCD Screen Advertisement Residence Life Student Legal Services Snapchat SRC Website Tell SomeoneOther referral source, if applicable:Availability for consultation during business hours (8 am – 4 pm M-F) Monday morning Monday afternoon Tuesday morning Tuesday afternoon Wednesday morning Wednesday afternoon Thursday morning Thursday afternoon Friday morning Friday afternoon I already have an appointmentAppointment Date/TimeIn most circumstances your visit will be kept confidential. Exceptions under the law include a court order, imminent danger to yourself and others, child abuse, sexual harassment and discrimination. These must be reported to the Office of Equal Opportunity and/or another appropriate authority. If your situation does not involve any of these circumstances, then all contacts, records, and communications will be kept confidential at Conflict Resolution Services. If you would like to talk to someone with full confidentiality privileges, please contact Counseling Services, the Women and Gender Advocacy Center, Student Legal Services, or personnel at CSU Health Network.Additional InformationEmailThis field is for validation purposes and should be left unchanged.
