STUDENT- Session Request

Welcome to COLLEGE TELEHEALTH! We have partnered with colleges across the nation to help support you in and beyond the classroom! We look forward to getting you started with our College Telehealth-Online Therapy.

If we partner with your college, you will receive a predetermined number of approved sessions at no cost to you. Fees are waived for students currently enrolled and verified by one of our partnering schools. If you do not see your school listed, use our private-pay request form.

✅ STEP 1: If your college is listed on the drop-down list of partnering schools, complete this quick form to get started.

✅ STEP 2: Once we verify your enrollment, College Telehealth will match you with a clinician in your state, who will reach out to you directly within 24hrs.

✅ STEP 3: College Telehealth will send you an email invitation to join our Client Portal. In your personal dashboard, you will be asked to complete our New Student Intake Consent Forms prior to your first session.

If you need any assistance or have questions, please contact us directly. Thank you! We look forward to getting you started!

The College Telehealth Team

What School Do You Attend? *

Student ID Number *

Required for Verification of Enrollment

State Located *

List Current Location

Last Name *

Student Name

First Name *

Student Name

Email *

Student Email

Phone number *

Student Phone

Referral Source *

Self-Referral Self Referral-Returning Student I am a faculty member making a referral with the student's consent

Preferred Session Times (Check all that apply) *

Morning Afternoon Evening (After 5) Anytime

Date of Birth *

Month Day Year

What are the primary concerns that you are seeking services for? *

Is there anything else you would like to share with our team? *

Would you be interested in Spanish Telehealth services, if available? *

No Yes(Si)

VIRTUAL COUNSELOR & COLLEGE TELEHEALTH

COLLEGE STUDENT-SESSION REQUEST

Client Portal & Intake Forms

24 Hour No Show Policy

Referral Source Information