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Shasta College Student Health & Wellness Office P.O. (Shasta College)

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Shasta College
Student Health & Wellness Office
P.O. Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006
Phone: (530)242-7580 / Fax: (530) 225-4968
www.shastacollege.edu/wellness
I > Wellness > Forms Brochures > Consent for Treatment, ADULTS 20200609 Revised by srl
Welcome to Shasta College Student Health & Wellness Office! The Student Health & Wellness Office maintains
personnel and facilities to assist you in maintaining and/or enhancing your health. The office has limited hours and
services are provided to assist District students with minor, temporary conditions that require only short-term care. The
Student Health Office is not a comprehensive health care provider and is not structured to address all of the healthcare
needs of District students. It is not the intention, nor contained in the scope of practice, of the healthcare professionals
in this office to be identified as primary healthcare providers.
RECORDS CONFIDENTIALITY
I understand that my treatment will be confidential and my records will not be released to anyone without my written
permission, except where required or permitted by law as Mandated Reporters to report to local and state agencies.
Mandated Reporters are required to report certain diseases; any knowledge or suspicion of child neglect or abuse
(including sexual exploitation), neglect or abuse of the elderly or dependent adults; when a patient is a danger to
himself/herself, another person or property (including the campus community); the patient is gravely disabled;
disclosure is court ordered; or emergencies. In the event that I am injured, hospitalized, or gravely disabled for any
reason, this document will serve as written consent to share confidential patient information as needed with
necessary college, healthcare, or law enforcement personnel. Fortunately these situations are infrequent. By signing
this form I also give permission to communicate with the Emergency Contact that I have designated if Student Health
Office staff believe me to be at-risk.
CONSENT FOR TREATMENT BY A MULTIDISCIPLINARY TEAM
Student Health Office personnel and contracted providers function as a multidisciplinary team for the purpose of
providing the most effective and efficient treatment possible. Under certain circumstances, medical and mental health
staff will exchange information regarding a student. This exchange will only occur when it has been determined that it
is in the best interest of the student, and only relevant information necessary to treat the student will be exchanged.
LATE and CANCELLATION POLICY
Medical appointments with the College Nurse and Physician are limited and require on time check-in. If you arrive
more than 15 minutes late to your appointment you may be asked to reschedule.
Therapeutic Counseling resources are limited. Regular attendance at counseling sessions is important to achieve
maximum benefit within the short-term counseling we provide. The number and length of sessions will be determined
by your counselor, based on your counseling needs.
If you arrive more than 15 minutes late to your appointment, you will not be seen and will be asked to reschedule. If
you do not show for your scheduled appointment or have repeated cancellations, you will be directed to use one of
the counselor’s daily Crisis Drop-In Visit times.
To cancel or re-schedule an appointment, please phone as far in advance as possible. Failure to do so will result as a
missed (No Show) appointment. Specific to missed appointments, we will assume that you have discontinued
treatment and will not automatically reschedule you for another appointment.
NOTICE REGARDING THERAPEUTIC COUNSELING
The Board of Behavioral Sciences receives and responds to complaints regarding services provided
within the scope of practice of (marriage and family therapists, licensed educational psychologists,
clinical social workers, or professional clinical counselors). You may contact the board online at
www.bbs.ca.gov, or by calling (916) 574-7830.
Shasta College
Student Health & Wellness Office
P.O. Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006
Phone: (530)242-7580 / Fax: (530) 225-4968
www.shastacollege.edu/wellness
I > Wellness > Forms Brochures > Consent for Treatment, ADULTS 20200609 Revised by srl
AUTHORIZATION AND CONSENT FOR TREATMENT
If I fail to return as directed for appointments, halt my recommended treatment prematurely, or do not comply with
the professional recommendation or community resource referral made by a practitioner, I understand that my
condition may worsen and/or health may be jeopardized. In such event I expressly acknowledge that the Student Health
Office, its employees and practitioner(s) providing services to me will not be responsible or liable for any negative
outcomes. I further understand that a determination may be made in accordance with applicable professional standards
as to whether the therapeutic duty offered by the Student Health Office, within the office’s scope of service, will be
terminated.
I understand that the Shasta College Student Health Office does not provide continuous and/or comprehensive health
care and that they will provide me with local community resources for ongoing health care. I also understand that
access to the services are based on enrollment status.
I authorize Shasta College Student Health Office to contact me using the phone number and / or email address listed
on my appointment intake forms.
I hereby state that I have read, understand, and agree to all of the above. That I have been given an opportunity to ask
questions, and that all questions have been answered in a satisfactory manner; and I understand that I am free to
withdraw my consent to treatment at any time.
I certify that I have read and understand the information provided above. My signature, either electronic or
handwritten, indicates I am informed and consent to the treatment.
____________________________________________ _________________________________________________
Print Name of Minor Student Signature of Minor Student
____________________________________________ _________________________________________________
Print Name of Parent / Legal Guardian Signature of Parent / Legal Guardian
____________________________________________ _________________________________________________
Phone Number for Parent / Legal Guardian Date
Student ID #__________________________________
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I:Wellness>Forms Brochures>Medical Provider History, Rev 20191205
SHASTA-TEHAMA-TRINITY COMMUNITY COLLEGE DISTRICT
STUDENT HEALTH & WELLNESS OFFICE
PO Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006, (530) 242-7580
Please complete ALL sections of this form. LEAVE NO BLANKS. Write none or N/A if not applicable. Thank you!
Today’s date: Time:
PATIENT INFORMATION
Patient’s last name: First: Middle:
Student ID #
Phone Number: Email Address: Birth date: Age:
What was your assigned sex at birth? Male Female
What is your current gender identity? Male Female
Transgender M F F M Other:
Emergency Contact:
Relationship to You:
Phone Number:
Marital Status: Single Married Other Divorced Unknown
Ethnicity: African American Caucasian Hispanic
Hispanic Latino Non-Hispanic Latino Other:
What is your country of origin (where were you born)?
Are you an International Student? Yes No
INSURANCE INFORMATION
Insurance information helps us to identify treatment options – we do not bill insurance.
Blue Cross Blue Shield Kaiser Health Net Aetna Veteran’s Medi-Cal Partnership Health Plan
International None Other:
Primary Care Doctor / Clinic:
What walk in / urgent care clinic(s) have you used in the past?
WHAT IS THE PROBLEM YOU WOULD LIKE HELP WITH TODAY? (List Symptoms like: Cough, Sore throat, rash, etc.)
DO YOU HAVE ANY ALLERGIES? Iodine Latex Medication Other, Please list:
Please list all medications you are taking right now (Prescribed or over-the-counter):
What is the date of your last menstrual period: Are you or could you be pregnant? Yes No
Do you: Smoke? Marijuana Cigarettes/Cigars Hookah Vape and/or Chew Other:
None
How many days a week do you drink alcohol? How many drinks a day (typically)?
Chronic Health Conditions: Arthritis Asthma Fainting / Dizziness Cancer Frequent Headaches Ulcers High Blood Pressure
Seizures / Convulsions Diabetes Tuberculosis Heart Problems Kidney Disease Mental Illness Other:
I have no chronic / ongoing health conditions
Are there currently any psychological / social issue confronting you that may be impacting your health? (i.e. relationship break up / job loss /
mood changes / etc.)
Patient signature:
Date:
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Completed 25 July 2020

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