On-line Comment Card The Mental Health team at UConn Student Health and Wellness is committed to continuous improvement, so we appreciate and value your feedback! Please let us know about your experience by completing the information below or give our Director a call at 860.486.4705. Please do not include any confidential information, appointment requests or prescription refill requests. This form is not intended for clinically related requests surrounding your care or your medical records. This is not intended as a secure form for sending medical information. We look forward to hearing your comments, concerns, and suggestions for improvement. Date of Visit Date Format: MM slash DD slash YYYY Time of Arrival at Arjona 4th floor : HH MM AM PM Type of Visit Appointment Walk-in Other Not Applicable Name First Last Peoplesoft # or Net IDPhoneEmail Would you like a response? (if yes, please ensure you entered your phone/e-mail address above) No Yes, at the phone number above. Yes, at the e-mail address above. Who did you see or what area did you visit?Please note your comments, suggestions and/or questions:CaptchaCommentsThis field is for validation purposes and should be left unchanged.