Request an appointment form

Student contact information

Phone(Required)

Student ID#(Required)

Date of birth(Required)

Presenting concern

What is your concern or reason for contacting us?(Required)

Is there a specific appointment date and time that you would like to request?

If yes, when and where?

Please call or text 988 immediately or visit https://988lifeline.org/talk-to-someone-now/.

Consent for services

I understand that the SSC Student Support Services Center offers a wide array of services free of charge to registered students, including individual counseling, group counseling, psychoeducational programs, consultation services and connection to community resources. I further understand that services provided are generally short-term (6 appointments), although longer-term services are available. SSC Student Support Services counselors will utilize any, all, or a combination of customary procedures and consultation practices employed in behavioral health care including health assessment and some counseling therapy techniques.

Initial(Required)

I understand that everything discussed with my counselor will be kept confidential with a few exceptions. I further understand that disclosure is mandated ethically and legally by the Ohio Counselor, Social Worker, and Marriage and Family Therapist (OCSWMFT) Board and/or the Ohio Revised Code in the following cases: 1) it is mandated by court order 2) suspected child/elder abuse and/or neglect, and 3) there is an expressed or significant concern of imminent risk of physically harming myself, another identified person, or an identified structure.

I understand that consultations with my psychiatrist and/or physician, mental health professional, other Stark State College faculty/staff, family members, peers, and/or other resources involved in my care will be done only after I have given written or verbal consent.

Initial(Required)

I understand that services will be provided by a member of the SSC Counseling Support Services Center staff. I further under-stand that the OCSWMFT Board requires that all counselor trainees (CT) and licensed professional counselors (LPC) meet with a supervisor on a regular basis to discuss my concerns. The purpose of supervision is to provide the highest quality of care for me and the supervisor is bound to the same laws of confidentiality. I also understand that in order to ensure the best possible care, consultation with other counseling professionals and supervisors is common during the counseling process and that during such consultation efforts are made to protect my identity.

Initial(Required)

I understand that the SSC Student Support Services Center will provide me with appropriate community referrals for counseling, case management, and psychiatric services as needed.

Initial(Required)

I understand that the SSC Student Support Services Center does not prescribe medications and will refer me appropriately to be assessed by a medical professional if medications are a recommendation for treatment.

Initial(Required)

Consent for follow-up

I hereby give the SSC Student Support Services Center staff consent to contact me by phone, email, letter, or in person for scheduling purposes, assess current or impending needs, and provide referral and/or follow-up information.

Initial(Required)

Privacy disclosure

I understand that although all attempts to maintain privacy will be made, electronic communication (such as email, text messages, voice over data calls, etc.) is not guaranteed to be secure.

Initial(Required)

Release of information

With my signature I hereby grant the above initialed consents.

Please type your full name for verification purposes as your electronic signature.(Required)

Name

This field is for validation purposes and should be left unchanged.

Student contact information

Presenting concern

Consent for services

Consent for follow-up

Privacy disclosure

Release of information

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