STUDENT HEALTH & UNIVERSITY COUNSELING CENTER
STUDENT ACCESSIBILITY OFFICE (SAO)
INITIAL CONTACT
NAME: ___________________________________ ID#: V00__________ SEX: _____________ DOB: ____/____/________
Date enrolled into VSU: Fall/Spring _______________ Insurance? Yes or No Insurance Provider: _________________________
Campus Address: ____________________________________________________________________________________________
Room # Residence Hall Box # Room Phone #
Permanent Address: __________________________________________________________________________________________
Street City/State Zip Code
Home Phone: __________________________________ Cell Phone: __________________________________
VSU Email: _____________________________________ Email: _______________________________________
PREFERRED METHOD OF CONTACT (please select one): □ Phone □ Email □ Mail
Who referred you to SAO? ___________________________________________________________________________________
How did you hear about our services? __________________________________________________________________________
CURRENT EDUCATIONAL STATUS: Please circle your classification as of today.
Classification/Credit Hours: FRESHMAN (<30) SOPHOMORE (30-59) JUNIOR (60-89) SENIOR (90+) GRADUATE STUDENT
Major: __________________________ Minor(s): ____________________ Are you currently having problems in class? Yes / No
Reason for visit: _____________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Have you received help with this problem before? Yes / No If yes, when was the last time? ______________________________
Do you have any concerns that may interfere with your studies at VSU? Please circle those that apply to you today.
Stress Finances Family Problems Relationship Problems Substance Use/Abuse
Legal Issues Sexual Assault Other: ____________________________
STUDENT SIGNATURE: _____________________________________________ DATE: __________________________
FOR COUNSELING STAFF TO COMPLETE: Indicate type of referral made, if any. Was an appointment scheduled? Summarize visit.
(Must be completed in its entirety and signed by a UCC staff member or trainee.)
_____Student Support Services _____Outpatient/External referral
_____Academic Support Center _____Personal Counseling ___________Appt. Date
_____Student Accessibility Office _____Substance Abuse Counseling
_____Financial Aid Office _____Crisis Counseling and MSE
Summary:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Revised 9/10/18 Staff Signature: _____________________________________________________ Date:
_
_____________
CONFIDENTIAL
NAME: _______________________________________________ V#: _________________________________________________
I hereby authorize Virginia State University Counseling Center (UCC) Student Accessibility Office (SAO) to release and receive infor-
mation concerning the above-named person to/from:
___________________________________________________________________________________________________________
(Name of Person or Organization)
___________________________________________________________________________________________________________
(Address)
___________________________________________________________________________________________________________
(Telephone and Fax Number)
Specify the type of information to be disclosed or exchanged:
I understand that the information is to be used for:
I understand that I can withdraw this consent at any time by contacting SAO in writing at the address below. These records may be
released via fax machine, secure email, written correspondence, telephone, or in person communication. A copy of this consent
and a notation concerning the persons or agencies to which disclosure was made shall be included with my original records.
This consent expires at the end of the academic year unless another date is specified: ________________ (Date)
Signature: ____________________________________________ Print Name: ___________________________________________
Phone Number: _______________________________________ Date: _________________________________________________
This form contains this students’ identifiable information and is intended for review and use for no one except authorized parties.
Misuse or disclosure of this information is prohibited by State and Federal Laws. If you have obtained this form as a mistake,
please send it to the address below:
Mail the original request form to : Virginia State University
University Counseling Center Student Accessibility Office
PO Box 9030
Petersburg, VA, 23806
STUDENT HEALTH & UNIVERSITY COUNSELING CENTER
STUDENT ACCESSIBILITY OFFICE (SAO)
CONSENT TO RELEASE INFORMATION
__ Assessment
_
_ Attendance
__ Treatment Summary
__Testing Reports
__ Recommendations
__ Disability Documentation
__ Psychological Records
__ Medication
__ Psychiatric Evaluation
__ Court Proceedings/Legal Records
__ Education Evaluation Information
__ Medical/Physical Evaluation
__ Treatment/Discharge Summaries
__ Substance Abuse Treatment
__ Social History
__ Acknowledgement of Client’s Presence in Treatment
__ Progress Notes
__ Disability Related Documentation
__ Other
__ Academic Consideration
__ Aftercare Planning
__ Contact with Referral Source
__ Family Involvement
__ Continuity of Treatment
__ Other: _______________________________
NAME: _______________________________________________ V#: _________________________________________________
I hereby authorize Virginia State University Counseling Center (UCC) Student Accessibility Office (SAO) to release and receive infor-
mation concerning the above-named person to/from:
__VSU Faculty/Staff__________________________________________________________________________________________
(Name of Person or Organization)
___VSU Campus
_____________________________________________________________________________________________
(Address)
____Numbers will vary________________________________________________________________________________________
(Telephone and Fax Number)
Specify the type of information to be disclosed or exchanged:
I understand that the information is to be used for:
I understand that I can withdraw this consent at any time by contacting SAO in writing at the address below. These records may be
released via fax machine, secure email, written correspondence, telephone, or in person communication. A copy of this consent
and a notation concerning the persons or agencies to which disclosure was made shall be included with my original records.
This consent expires at the end of the academic year unless another date is specified: ________________ (Date)
Signature: ____________________________________________ Print Name: ___________________________________________
Phone Number: _______________________________________ Date: _________________________________________________
This form contains this students’ identifiable information and is intended for review and use for no one except authorized parties.
Misuse or disclosure of this information is prohibited by State and Federal Laws. If you have obtained this form as a mistake,
please send it to the address below:
Mail the original request form to : Virginia State University
University Counseling Center Student Accessibility Office
PO Box 9030
Petersburg, VA, 23806
STUDENT HEALTH & UNIVERSITY COUNSELING CENTER
STUDENT ACCESSIBILITY OFFICE (SAO)
CONSENT TO RELEASE INFORMATION
__ Assessment
_
_ Attendance
__ Treatment Summary
__Testing Reports
__ Recommendations
__ Disability Documentation
__ Psychological Records
__ Medication
__ Psychiatric Evaluation
__ Court Proceedings/Legal Records
__ Education Evaluation Information
__ Medical/Physical Evaluation
__ Treatment/Discharge Summaries
__ Substance Abuse Treatment
__ Social History
__ Acknowledgement of Client’s Presence in Treatment
__ Progress Notes
__ Disability Related Documentation
__ Other
__ Academic Consideration
__ Aftercare Planning
__ Contact with Referral Source
__ Family Involvement
__ Continuity of Treatment
__ Other: _______________________________
STUDENT HEALTH & UNIVERSITY COUNSELING CENTER
STUDENT ACCESSIBILITY OFFICE (SAO)
CONSENT TO RELEASE INFORMATION
Regarding Our Information Forms and Service
The purpose of the following informational questionnaires is to obtain as comprehensive a picture of your background and con-
cerns as possible so that we may best service your needs. Please answer the questions as honestly and accurately as you can. All
records at the Counseling Center Student Accessibility Office are confidential.
Regarding Confidentiality
We realize that the concerns you bring to our office are highly personal in nature. We assure you that all of the information shared
b
oth verbally and in writing will be managed within the legal and ethical conditions of confidentiality. This means that information
will not be released to anyone except under the following conditions:
1. When our counseling staff feel the need to seek supervision, we may consult with professional colleagues within our agency.
This will aid us in our work with you.
2. If we believe that you pose a life-threatening risk to yourself or someone else, we must notify responsible individuals to pre-
vent any harm from occurring.
3. If you are under 18 years of age and the victim of physical or sexual abuse, we are required to report relevant information to
child protective services to prevent further abuse from occurring. Additionally, if you disclose information regarding the
physical or sexual abuse of a minor, we are also required to report relevant information to child protective services.
4. If you are involved in a legal action and a judge determines that clinical information will provide evidence bearing significantly
on the case, he or she may subpoena or legally compel the therapist to release information from your records.
5. In case of any malpractice action against counselors on staff, the counselor may disclose information from the case that is nec-
essary or relevant to the counselor’s defense.
6. When your counselor is receiving supervision, a consent form to discuss your case with the supervisor will be fully discussed
and signed giving your consent to this.
7. For the purpose of evaluating our services, gathering valuable research information, and designing future programs, the Coun-
seling Center Student Accessibility Office staff may utilize your clinical information; however, your anonymity will be main-
tained through the use of a client identification number, which is different from any identifying data such as a social security or
student ID number.
8. All counseling records may be stored on a secured computer system. n If this occurs, confidentiality will be maintained
through Novell Security and database security roles.
9. All case files are the property of the University Counseling Center Student Accessibility Office.
In all other situations, information may be released to appropriate individuals or agencies ONLY UPON YOUR WRITTEN REQUEST.
I have read and understand that these conditions of confidentiality apply to being identified as a client, as well as any information
shared verbally or in writing to my counselor.
_____________________________________ ________________________________________________________
(Date) (Signature)
If you have any questions about this form, your intake counselor will be glad to discuss the information with you.
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