Confidential Counseling Self-Referral Form Confidential Counseling Self-Referral FormRefer yourself for counseling services at Taft College by completing the form below. "*" indicates required fields Student InformationName* First Last Student ID Email* Phone*Please tell us how to contact you.Check box(es) where messages may be left: Home Cell Email Emergency ContactEmergency ContactName of Emergency ContactRelationshipRelationship to Emergency Contact.Emergency Contact PhonePhone Number of Emergency Contact.Check Here to give permission to contact I permit contact. Check this box if you give permission to contact this individualCurrent ConcernsPlease explain your reason for requesting services.Are you thinking of killing yourself? Yes No Please choose Yes or No.Are you thinking of harming or killing another person? Yes No Please choose Yes or No.Are you having suicidal thoughts? Yes No Please choose Yes or No.Please check any Stressful Events That May Apply to You. Depression Grief and loss Addiction or recovery issues Difficulty adjusting to life changes Parenting issues Anxiety Victim of abuse Relationship issues LGBT issues Other Please check all that apply.OtherPlease tell us about the Stressful Event.Rate your current level of distress MINAMAL MILD MODERATE SEVERE Have you ever received mental health counseling before? Yes No If “Yes,” please give the name of previous counselor, or agencyDo you have a primary care physician (PCP)? Yes No If “Yes,” please give the name of your PCP and their clinicDo you have insurance? Yes No If so, what typeCAPTCHA
