VIRTUAL COUNSELOR & COLLEGE TELEHEALTH
www.VirtualCounselor.com
Referral Source
*
Self
Minor under my care
I am making a referral for someone
Client or Student Information
Please include information based on current location
Last Name
*
First Name
*
Email
*
Phone number
*
State of Residence
*
LIst Current Location
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
How would you prefer we contact you to schedule?
*
Email
Phone
Either
May we send you text messages?
*
Yes
No
What are the primary concerns that you are seeking services for?
Anxiety
Depression
Relationship Concerns
Anger
Traumatic Experience
Grief
Behavioral Concerns
Academic Stressors
Ongoing Mental Difficulties
COVID Related Stressors
Is there anything else you would like to share?
*
Would you be interested in Spanish Telehealth services, if available? ¿Estarías interesado en los servicios en español, si estarían disponibles?
No
Yes(Si)
College Student Information
If your college partners directly with College Telehealth, please complete this section so we can verify your enrollment.
Student ID Number ( or N/A)
*
School(or N/A)
*
Are you enrolled for the current semester or upcoming semester?
*
Yes, Spring 2021
This does not apply to me.
Back
Next
Client Portal & Intake Forms
Upon scheduling a full session, you will be provided an email invitation to our client portal. We request that you complete all intake documents 24 hrs prior to your initial session. During your intake session, your assigned clinician will review the forms in detail and answer any questions you may have.
24 Hour No Show Policy
If you would like to cancel a scheduled session, we kindly ask that you provide at least 24-hour notice.
Back
Next
Referral Source Information
If you are making this referral on behalf of someone else, please complete this section.
Referral Source's Name
School or Business Name
Email
Phone Number
Additional Information
Upload Additional Documents
Browse Files
This Folder is HIPAA Secure
Cancel
of
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm