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?*

Are you coming in to address a recent death/loss of someone important to you?*

YesNo

Are you coming in to address an experience involving a recent assault or harassment situation?*

YesNo

Are you experiencing thoughts of harming yourself or someone else?*

YesNo

if YES please call 911 immediately, this is not an interactive 24 hour monitored communication system

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

Date

With Whom

Have you ever been hospitalized before?*

if yes, dates

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.*

YesNo

I have reviewed the information in the Orientation Packet, located on the website, and have received my Notice of Privacy Practices.*

Yes

I agree to download and review the Student Counseling TeleHealth Services Informed Consent to be reviewed by my counselor in session.*

Yes

Telehealth Consent Form

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.*

YesNo

Campus Information*

Location*

Please Upload a Picture of your Government Issued ID

Picture of government issued ID*

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