BC - New Student Online Forms

PLEASE NOTE: Questions in this registration will refer to the ORIENTATION PACKET that is located on our webpage ORIENTATION PACKET under the FORMS tab.
Name *

First Name Last Name
Student ID *
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender *
Sexual Orientation *
Email *
example@example.com
Local Address (If different than above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you a Veteran? *
Are you a Smoker? *
Cell Phone Number *
Please enter a valid phone number.
Preferred? *
Home Phone Number
Please enter a valid phone number.
Preferred?
Primary Language Spoken in the Home *
How did you hear about us? *
Do you have insurance? *
Company Name If Yes
Member #
Group #
Which academic program are you in? *
Race *
If Other
What would you like to focus on in counseling? *
If you are experiencing thoughts of hurting yourself or others please call 911 immediately.
EMERGENCY CONTACT: By filling in the information below, I give permission to speak to my Emergency Contact if necessary
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Address
Relationship to you *
Medical and Counseling Information
Are you being treated for any medical condition? *
If yes, Describe
Are you taking medications? *
If yes, Name and Dosage
Reason for medications
Name of Doctor
Phone Number
Please enter a valid phone number.
Have you ever been in counseling before? *
If yes, dates

Month Day Year
Date
With Whom
Have you ever been hospitalized before? *
if yes, dates

Month Day Year
Date
If yes, for what?
Please select YES if you give your permission to allow HSCS to speak with BC officials should there be a perceived incidence of threat due to the growing occurrence of violence on college campuses nationwide. *

Yes No
I have reviewed the information in the Orientation Packet, located on the website, and have received my Notice of Privacy Practices. *

Yes No
If I choose to participate in telehealth services, I agree to download and review the Student Counseling TeleHealth Services Informed Consent to be reviewed by my counselor in session. *

Yes No
Please select YES if you give permission to allow the Henderson Behavioral Health psychiatrist to access your medication history data for use when prescribing medication, only if receiving services with the psychiatrist. *

Yes No
Telehealth Consent Form
Campus Information *
Location *
Please Upload a Picture of your Government Issued ID
Picture of government issued ID *

Cancel of
By clicking Submit, I confirm that I have reviewed the FAQs
Should be Empty:

If you are experiencing thoughts of hurting yourself or others please call 911 immediately.