Fillable Counseling Request (Las Positas College)

Fill Online, Printable, Fillable, Blank Counseling Request (Las Positas College) Form

Use Fill to complete blank online LAS POSITAS COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Counseling Request (Las Positas College)

On average this form takes 52 minutes to complete

The Counseling Request (Las Positas College) form is 8 pages long and contains:

  • 1 signature
  • 187 check-boxes
  • 117 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Las Positas College

BROWSE LAS POSITAS COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FOR COUNSELOR USE ONLY:
TERM: FALL: □ SPRING: □ SUMMER: □ YEAR: _____ INTAKE #: _______
Electronic Counseling Request PDF 4/21/2020
Counseling Request
Name: ____________________ W# ____________________
Zonemail Email: ___________________ Date: ___________________
Days and Times Available
PLEASE CHECK ALL TIMES AVAILABLE
HOURS
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
9:00 am
9:30
10:00
10:30
11:00
11:30
12:00 pm
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
Counselor Notes: (Use this section to provide additional notes for counselor and/or e-mail address if desired)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CLEAR FORM
Date:W Number:Name:_______________________________ ________________ __________
CONSENT FOR TREATMENT
In the case of mental health services (personal therapy) permission is hereby granted to treat the
student named below at the Las Positas Student Health and Wellness Center, and to make necessary
referrals to private outside care, emergency mental health, and/or other community facilities as
indicated or needed.
____Click here to electronically give permission for the Las Positas College Student Health and
Wellness Center to contact you via email. Please use assigned Zone Mail Account
Check all that apply:
I give permission for counseling session by phone ____
I give permission for counseling by Telemedicine ____
Please return all forms to pgonsman@laspositascollege.edu
ATTENDANCE POLICY
Our office requires notification of cancellation at least 24-hours prior to the appointment or earlier if
possible. A NO SHOW will be assigned to the appointment if we do not hear from you. Two (2) missing
appointments, without notification, will result in your appointments being cancelled. If that occurs you
will need to resubmit a request for services and you will be contacted by the next available AMFT for
sessions. (Please note those sessions will pick up at the number you left on).
CONSENT FOR CARE
"By signing, I understand that failing to give a notice within 24 hours or "NO SHOWING" of an
appointment will result in the aforementioned results. Further, I certify that I have been informed of
my rights and responsibilities, the rules of confidentiality, and the responsibilities of the Las Positas
Student Health and Wellness Center and the Associate Marriage and Family Therapists for onsite care."
Date:Student Signature: ________________________________ _____________
Date:Witness: ________________________________________ _____________
Electronic Information Form
04/21/20
Information Form
Counseling Client
Name: Age: DOB:
Gender: FEMALE MALE TRANSGENDER (Check one) Email:
W# Cell Phone:
Home Phone:
Email Address:
OK to leave a message? YES NO
Mailing Address:
Street Address City
Do you live with your parents? YES NO If yes, please list your parent’s names:
Emergency contact: Name:
Relationship: Telephone:
How long have you been attending Las Positas College?
Have you ever received counseling services at Las Positas College? YES NO If yes, counselors
name and year you received counseling:
What is your current occupation?
*************************************************************************************
Please describe presenting concerns for seeking counseling at this time:
What are your best hopes for the session(s)?:
Have there been any significant stressors or traumas in your life: losses, births, deaths, moves,
hospitalizations, financial problems, in the last few years?
Have you had any current or past psychiatric treatment or counseling? YES NO If yes, please explain:
Electronic Information Form
04/21/20
Have you been hospitalized for any psychological care? YES NO If yes, what was the presenting
issue?
Have you ever been suicidal? YES NO If yes, please explain:
Are you currently having suicidal thoughts? YES NO If yes, please explain:
Do you have any special needs? YES NO If yes, please explain:
Are you currently taking any prescribed medications? YES NO If yes, what are you taking?
Are you currently being treated for any chronic medical conditions? YES NO If yes, please
explain
Have you had any serious illnesses, accidents, or surgeries in the past? YES NO If yes, please
explain:
Please mark an “X” by the appropriate description if you are experiencing any of these symptom
Academic Stress
Anger Problems
Anxiety
Depression
Eating Disorder
Family Problems
Hearing Voices
Financial Stress
Grief/Loss
Low Self-Esteem
Mood problems
Sexual Abuse
Sleeping Problems
Social Discomfort
Vocational Stress
Clients Signature Date
click to sign
signature
click to edit
Electronic Information Form
04/21/20
Are you currently using alcohol/drugs (amount, how often, intoxication frequency)?
What is your personal history of any alcohol/drug use?
Has anyone in your family used alcohol or drugs? YES NO (Circle one) If yes, please explain
Does any member of your family have mental illness? YES NO If yes, please explain:
Describe your current relationship satisfaction with your family:
Mother:
Father:
Siblings:
Additional Notes:
TERM: FALL: □ SPRING: □ SUMMER: □ YEAR: ____ INTAKE #: _______
TERM: FALL: □ SPRING: □ SUMMER: □ YEAR: ____ INTAKE #: _______
Las Positas College
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT FORM
“Notice of Privacy Practices” has been made available to me.
Client Signature Date
TEXT
“COURAGE” to 741741
CALL
1-800-273-TALK (8255)
ONLINE
www.ulifeline.org/laspositascollege
La Familia Servicios Psico-Sociales:
1149 N. El Dorado Street, Stockton, CA 95202 (209) 468-2335
Mental Health Services Vocational Rehabilitation Services:
1212 N. California Street, Stockton, CA 95202 (209) 468-8842
Medi-Cal Counseling:
Alameda County: ACCESS PROGRAM: 1-800-491-9099
Contra Costa County: ACCESS PROGRAM: 1-888-678-7277
San Joaquin County: ACCESS PROGRAM: 1-209-468-9370
NAMI:
35 10
th
St. Ste. B, Tracy, CA 95376 (209) 468-3755
Tracy Adult Outpatient Clinic:
220 W. 11
th
Street, Tracy, CA 95376 (209) 831-5941
Tri-Valley Sliding Scale Counseling:
Anthropos Counseling Center: (925) 449-7925 Counseling@Anthroposcounselling.Org
Pleasanton Community Counseling Center: (925) 600- 9762
Tri Valley Haven Counseling Center: (925) 449-5845
Website to help find a therapist covered by your insurance co.
https://www.psychologytoday.com/
Las Positas College Student Health & Wellness Center
Counseling Services Referrals
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Counseling Request (Las Positas College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 September 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document