Counseling Policies & Intake Form

Date:*

Date

Welcome to the Student Counseling and PERC Case Management Center. We are so proud of your decision to take the first step in finding the emotional support that you need. The Counseling Center will make every effort to schedule an appointment for you to meet with a counselor as quickly as possible. Despite our best efforts, we sometimes cannot accommodate you with an appointment as soon as you would like. Most students who are not in URGENT NEED will typically be contacted for scheduling within a week of initial appointment inquiry. If we are unable to assist you in the time that you require, we will refer you to community resources. It is your responsibility to follow up with these resources and schedule your appointments. If the level of care required is outside of the scope of the counseling center we reserve the right to refer you to a community resource or differing department that can best meet your needs.

What is URGENT NEED CRITERIA?

· You have been thinking of hurting yourself in any way

· You have been thinking of taking your own life

· You have been thinking of hurting someone else in any way

· You see or hear things that other people do not see or hear

· You have experienced or witnessed a traumatic event

Services

The Student Counseling Center provides individual and group counseling and case management services at no charge to currently enrolled and registered students. If you are not currently enrolled and registered, we will provide you with a list of alternate community resources.
The delivery and services from the Student Counseling Center shall be contingent upon whether the Student Counseling Center staff and you can agree that our services are appropriate given your needs and presenting conditions. If it is decided that this is not the appropriate place for you to be seen, referrals to more appropriate resources will be provided.
Students who are in URGENT NEED will meet with a counselor as soon as possible to determine the best course of action regarding ongoing services. Please speak with your assigned counselor if you have any questions.
New clients (students) are scheduled for the first available counselor that meets your scheduling needs.
Psychiatric services are NOT provided through the Student Counseling Center.

Students of Concern Confidentiality Exception

If circumstances warranting such discussion for the purpose of a threat assessment or safety concerns confidentiality may be extended to the Dean of Students, Security, and/or the Panther Care Team. Please refer to the Student Handbook for further description of the Panther Care Team. You will be provided more information on the limits of confidentiality at your first appointment.

Student Responsibilities

It is your responsibility to be on time.
If you are unable to keep your appointment, or will be late, please call our counseling center at 561-868- 3980 to reschedule. We expect you to cancel your appointment with at least 24 hours’ notice.
If two consecutive appointments are scheduled and not kept, we cannot guarantee continued treatment with your assigned counselor.
You will be required to complete intake forms and a discharge survey as part of your treatment agreement.
You are responsible for updating us with any changes in contact, or other, information.
You are responsible for completing updated intake paperwork each semester.

Training

The Palm Beach State College Student Counseling Center is overseen by a Licensed Clinical Social Worker.
The Student Counseling Center is a training facility for graduate students completing their mental health counseling or social work degrees. Cases are discussed in supervision and clinical staff meetings to provide you with the quality services that you deserve.
If you have any concerns regarding your treatment, you may contact your counselor’s supervisor. Please know that this does not automatically mean that you will be assigned to a differing counselor.

Student ID Number:*

Student ID Number

Student Name:*

First NameLast Name

Date of Birth:*

Date

Age:*

Primary Campus:*

Primary Language: *

Address:*

Street Address

Street Address Line 2

CityCounty

Postal Code

PBSC Email: palm@my.palmbeachstate.edu*

We will not use your personal email address. We will only use your PBSC email to ensure confidentiality.

Mobile Phone:*

Please enter a valid phone number.

Is the number you provided a safe number to contact?*

Preferred Method of Contact:*

E-mailMobile Phone

Relationship Status:*

Name:*

First NameLast Name

Phone Number:*

Relationship:*

Are you currently experiencing any thoughts of ending your own life?*

Yes If yes contact 911 immediatelyNo

Have you ever thought of ending your own life in the past?*

YesNo

If yes, please provide details of your previous suicide attempts or thoughts. If no, continue to next question:

Have you harmed yourself in any other way? *

YesNo

If yes, please provide details. If no, continue to next question:

Are you currently experiencing any thoughts of harming another person? *

YesNo

If yes, please describe thoughts, plan, and means below.

Do you engage in any behaviors someone might describe as addictive? *

YesNo

If yes, please list and describe how often you engage in the behavior(s):

Have you seen a counselor, psychologist, psychiatrist or other mental health professional either currently or in the past?*

YesNo

Type a question

If yes, please briefly explain why and if you found/are finding it helpful:

Have you ever received counseling or case management services from Palm Beach State College Student Counseling Center in the past?*

YesNo

If yes, please describe whom you worked with, what services were provided, and what semester?

Do you have any official mental health diagnosis?*

YesNo

If yes, please list below and state dates of diagnosis and who provided diagnosis:

Have you been hospitalized for any mental health conditions in the past six months?*

YesNo

If yes, please describe:

Are you taking any prescription medication relating to your mental health?*

YesNo

If yes, please list below:

Are you currently taking medication as prescribed?*

YesNoNot Applicable

If no, please briefly explain why not:

Please explain briefly what the main issues you are seeking counseling:*

What are your main goals to be achieved during counseling? *

Are you interested in a support group? If so, which?

NAMI (Certified peer led mental health support group) Lake WorthCreating a Healthier Life - Step by Step Guide to Wellness - Lake WorthCreating a Healthier Life - Step by Step Guide to Wellness - Boca RatonCreating a Healthier Life - Step by Step Guide to Wellness - Palm Beach GardensCreating a Healthier Life - Step by Step Guide to Wellness - Belle Glade/LoxahatcheeCreative Expressions- Lake WorthOther

Please state the best times and days that you would prefer your appointment: *

The dates and time you select are not guaranteed.

What campus do you prefer?*

I understand that once I submit this form, I do NOT automatically have a set scheduled appointment. I only indicated my preferences which will be considered. *

I understand that after I submit this form, I will be contacted by a Counseling Center staff member via the contact information I provided on this form to schedule my appointment. *

Is there anything else you would like us to know?

*Your signature below indicates that the information you have provided above is truthful.

Date:*

Date

Print Student Name*

Student Signature:*

Palm Beach State College Student Counseling Center Policies & Intake Form

Emergency Contact Information

Mental Health History Information

Reason For Counseling