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Confidential Counseling Self-Referral Form
Confidential Counseling Self-Referral Form
Refer yourself for counseling services at Taft College by completing the form below.
"
*
" indicates required fields
Student Information
Name
*
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 Contact
Emergency Contact
Name of Emergency Contact
Relationship
Relationship to Emergency Contact.
Emergency Contact Phone
Phone Number of Emergency Contact.
Check Here to give permission to contact
I permit contact.
Check this box if you give permission to contact this individual
Current Concerns
Please 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.
Other
Please 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 agency
Do you have a primary care physician (PCP)?
Yes
No
If “Yes,” please give the name of your PCP and their clinic
Do you have insurance?
Yes
No
If so, what type
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