VIRTUAL COUNSELOR & COLLEGE TELEHEALTH
Minor under my care
I am making a referral for someone
Client or Student Information
Please include information based on current location
State of Residence
LIst Current Location
Date of Birth
Date Picker Icon
How would you prefer we contact you to schedule?
May we send you text messages?
What are the primary concerns that you are seeking services for?
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?
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)
Are you enrolled for the current semester or upcoming semester?
Yes, Spring 2021
This does not apply to me.
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.
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
Upload Additional Documents
This Folder is HIPAA Secure
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm