Conflict Resolution Appointment Request Form Name* First Last Preferred Name Pronouns CSU ID #* Email* Phone*Which 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 Sophomore Junior Senior Master's Student Doctoral Student Which of the following are you enrolled in:* On-campus degree program/classes CSU Online degree/certificate program Not sure Other Are you a first generation college student? Yes No Are you a veteran? Yes No Please indicate which of the following you most identify with (check all that apply): Asian Black, Afro-Caribbean, or African American Latinx, 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 would you like to discuss with Conflict Resolution staff (check all that apply)?* Academic Misconduct Appeals Accommodations/Accessibility Bias/Discrimination Course content/structure Concerning/Disruptive behavior Conduct case Conflict Dynamics Profile Covid-19 Criminal citation CSU policies/Procedures Degree progress/Requirements Employment/Supervision Professor/Instructor CSU staff Financial matters Grading/Evaluation Graduate Advisor/PI Interpersonal violence Roommate(s)/Living Situation Organization/Team/Club Personal Relationship Self-Improvement/Skill-building Other Brief description of the situation:*How did you learn of Conflict Resolution Services? Academic Advisor Ads on Campus Student Student Case Management Court CSU Staff Health Network Ombuds Presentation/Event Professor/Instructor Student Disability Center Social Media Student Resolution Center Student Legal Services Tell Someone University Housing Web Search/Google Other Please specify: When are you typically available to meet? (check all that apply)*Appointments generally last 45-60 minutes. Office hours are 8:00AM-5:00PM (mountain time), Monday through Friday. I already have an appointment Mondays Tuesdays Wednesdays Thursdays Fridays Mondays between the hours of:* 8:00AM-11:00AM 11:00AM-2:00PM 2:00PM-5:00PM Tuesdays between the hours of:* 8:00AM-11:00AM 11:00AM-2:00PM 2:00PM-5:00PM Wednesdays between the hours of:* 8:00AM-11:00AM 11:00AM-2:00PM 2:00PM-5:00PM Thursdays between the hours of:* 8:00AM-11:00AM 11:00AM-2:00PM 2:00PM-5:00PM Fridays between the hours of:* 8:00AM-11:00AM 11:00AM-2:00PM 2:00PM-5:00PM How would you prefer to meet?* 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) No preference Do you require a disability related accommodation for this meeting? Yes No Please specify:Do you need translation services? Yes No For translation services, please select one of the following languages:N/AArabicBosnianBrazilian PortugueseCambodianCantoneseCroatianFarsiFrenchGermanHaitian CreoleHindiHmongJapaneseKoreanLaoMandarinPunjabiRomanianRussianSerbianSomaliSpanishThaiTagalogVietnameseCONFIDENTIALITY:*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. PhoneThis field is for validation purposes and should be left unchanged.