Student Well-being and Mental Health Services (SWHMS)

Please complete the form below, once received a team member from Student Well-being and Mental Health Services will provide you with an appointment confirmation via email. If you have any questions or need assistance with completing the form, please email medwellness@fiu.edu. Thank you, and we look forward to supporting you during your medical school journey.

Please Note: This form is to be completed ONLY by admitted M1-M4 students attending HWCOM. Unfortunately, we do not provide services to international medical school students, or PA students at this time. Any other student needing mental health services should reach out to FIU CAPS for further assistance. 305-348-2277 (CAPS)

Name Name First Last
Panther ID
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Academic Rank

Academic Rank M1 M2 M3 M4
Are you a US medical student registered at HWCOM? (This office only serves medical students at FIU HWCOM)

Are you a US medical student registered at HWCOM? (This office only serves medical students at FIU HWCOM) Yes No; If No, Please stop completing this form and contact CAPS for further assistance at 305-348-2277
Is this your first time requesting an appointment with SWHMS?

Is this your first time requesting an appointment with SWHMS? Yes No
Is this request for an urgent matter? If this an urgent request and is completed after business hours, please contact 9-8-8, 9-1-1, or FIU CAPS afterhours phone number 305-348-2277.

Is this request for an urgent matter? If this an urgent request and is completed after business hours, please contact 9-8-8, 9-1-1, or FIU CAPS afterhours phone number 305-348-2277. Yes, I would to request an urgent appointment and I am a new client Yes, I would like to request an urgent appointment with the first available therapist No, I can wait for the next available appointment
If this is not your first time meeting with SWHMS, please select the way in which you would like to meet with your therapist.

If this is not your first time meeting with SWHMS, please select the way in which you would like to meet with your therapist. In-Person Telehealth Phone
SWHMS Appointments-Scheduling
Please provide us with 3 dates to assist with scheduling. Keep in mind, first time therapy appointments typically last 60 minutes, so please plan accordingly when providing date/time options below.
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM