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 NameLast Name
Student ID*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Sexual Orientation*
Email*
example@example.com
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?*
What is your major?*
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.
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 NameLast 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?*
Have you ever been hospitalized before?*
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
What is your home/main campus?*
Where do you prefer to attend counseling sessions?*
Please Upload a Picture of your Government Issued ID
Picture of government issued ID*

Cancelof
By clicking Submit, I confirm that I have reviewed the FAQs
If you have trouble attaching an image, please call us at (954) 424-6916
Should be Empty:

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