THIS IS NOT AN EMERGENCY CRISIS FORM. 

IF YOU NEED TO SPEAK TO A LICENSED PROFESSIONAL IMMEDIATELY, CALL (855) 364-7981 

or 

IF THIS IS AN EMERGENCY, CALL 911.




Psychological Counseling Services

If you are a new client to Psychological Counseling Services, please complete the Intake, Informed Consent, and Psychological Counseling Services Email usage forms.


WHAT IS COUNSELING?
PCS Counseling is provided to currently enrolled students. Counseling is a confidential process through which clients learn skills, make new decisions, plan their lives, and deal with feelings and communications in new ways.


WHAT CAN YOU EXPECT?
You can expect an emotionally safe environment where you will be welcomed, listened to, and heard. Expect assistance in a process of change and self-understanding.


WHAT WILL BE EXPECTED OF YOU?
Please do your best to be as open and honest as possible. Commit to working on your concerns through a collaborative relationship that involves mutual responsibility.


TELEHEALTH APPOINTMENTS

Hours of operation: Monday-Friday 9am-5pm (Walk-ins from 12pm-1pm) 

Appointment format: Phone or Zoom 

 Summer Hours: None

 Closed for Campus Holidays

 After Hours Crisis Services available by calling: 855-364-7981


As you may be aware, there has been a high demand for counseling services at PCS. We will appreciate your assistance in the efficient management of appointments.

If you are unable to keep an appointment, please call us ahead of time. At least 24 hours prior notice of a cancellation would be most helpful.

Session time is generally 45-50 minutes.

Due to budget constraints and high student demand for services, failure to show or cancel appointments ahead of time may result in difficulty obtaining another appointment.

Availability of counseling sessions may be limited, depending on the number of students requesting sessions at a particular time of year and availability of counselors.



COUNSELING ASSESSMENT PROCESS


The first meeting and initial phase of counseling typically involves an assessment of your concerns, review of background information, determination of goals, and identification of the services most appropriate to address your concerns and goals.

If your needs are better met by services available elsewhere, or if you are not eligible for our services, we will provide referral information and assist you in obtaining other services. Your therapist may terminate with you if he/she cannot provide therapy that fits your specialized treatment needs, if you do not comply with the mutually developed treatment goals and procedures, if you are not benefiting from therapy, if you become violent, abusive, or if the therapy relationship is compromised in any way due to unforeseen circumstances.


CONFIDENTIALITY AND LIMITS

The information disclosed by you in your counseling sessions is generally kept confidential. However, there are exceptions to confidentiality including, but not limited to the following:

* If your counselor determines that you are in imminent danger of self-harm
* If there is reason to suspect child, elder, or dependent adult abuse
* If a person knowingly develops, duplicates, prints, downloads, streams, or accesses through any electronic or digital media, a film, photograph, or video in which a child is engaged in an act of obscene sexual conduct
* Expressed threats of violence towards an ascertainable victim
* If your records or other information are sought by federal law enforcement officials under the United States Patriot Act (see below)
* By a court order or subpoena from an attorney

Further, your counselor may consult with health care professionals at the CalArts Student Health Center if medical consultation is deemed necessary, with Disability Services Office, and also with other professionals from whom you have received or currently are receiving medical or psychological treatment.

While your written consent for consultation with other professionals who are treating you is not required, you will be kept informed regarding the nature and extent of such consultations. Finally your counselor reserves the right to consult with his or her professional colleagues here in Psychological Counseling Services. The counselors all work under the same pledge to maintain the confidentiality of all students receiving services here.


United States Patriot Act
The Congress of the United States of America has recently passed legislation called the Patriot Act. This legislation enables government law enforcement officials to access confidential information about you if they have determined that you may represent a terrorist threat to the national security of the United States. In addition, the personnel of Psychological Counseling Services would NOT be able to inform you that the government had contacted them about you.


Military or Government Service
If you are enterin
g or are in the military, or if you are in government employment that requires that you obtain security clearance, Psychological Counseling Services may be contacted about confidential services you have received here. In this case, we would make every effort to gain your permission in writing before we release this information.

Therapy Request Form

Date of Submission *
Student's Name*
Date of Birth *
Gender
Pronouns

Personal Contact Information

Address*
ex. XXX-XXX-XXXX
Emergency Contact*
Emergency Contact Address*

Medical Information

Psychotherapy Information

Have you ever participated in psychotherapy or counseling before?
Have you ever been hospitalized for mental health reasons?*
Are you currently experiencing any thoughts/plans of suicide?*
Have you in the past experienced any thoughts of suicide?*
Availability
Availability
  9:00am 10:00am 11:00am 12:00pm 1:00pm 2:00pm 3:00pm 4:00pm
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Method for Therapy *

TELEHEALTH INFORMED CONSENT

I hereby consent to engage in TeleHealth with Psychological Counseling Services. TeleHealth is a form of counseling service provided via telephone/video conferencing. I understand that TeleHealth involves the communication of my mental/medical health information, both orally and/or visually.


TeleHealth has the same purpose or intention as counseling treatment sessions that are conducted in person. However, due to the nature of the technology used, I understand that TeleHealth may be experienced somewhat differently than face-to-face counseling sessions. It is important to be aware that TeleHealth may or may not be as effective as in-person counseling and your counselor will need to evaluate if TeleHealth is an effective form of treatment for each client.


Client’s Rights, Risks and Responsibilities


1. The client must reside in California when all TeleHealth services are provided.
2. The client has the right to withdraw consent for use of TeleHealth services at any time.
3. The laws that protect the confidentiality of my treatment also apply to TeleHealth. Also, the mandatory and permissive exceptions to confidentiality that apply in face-to-face counseling, also apply to TeleHealth.
4. The client understands that there are risks and consequences of participating in TeleHealth, including, but not limited to, the possibility, that the transmission of my information/session could be disrupted or distorted by technical failures; that my information/session could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
5. The client understands that there may be a benefit in using TeleHealth, but that results cannot be guaranteed or assured.
6. The client understands that emergency services are not provided when using TeleHealth, but in the event of an emergency, your counselor will provide information on resources in your area.
7. The client understands that there is a risk of being overheard by anyone near them if not in a private area while participating in TeleHealth. TeleHealth services will not be provided when the client is in a moving vehicle. The client is responsible for (A) providing the necessary computer, telecommunications equipment and internet access for all TeleHealth sessions, and (B) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for all TeleHealth sessions.


Emergency Contact
The person you indicated as your Emergency Contact at the time of your intake will only be contact in an
emergency situation.


Electronic Communication
Please know that e-mail communication is NOT considered a confidential medium of communication.
Therefore, it is preferable that you communicate with your counselor or with Psychological Counseling
Services by phone or in person.
 


Notice to Clients

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.



If you have needs of an urgent nature after hours, you may contact 911 or
the Campus Safety at 661-222-2702. 


Checkbox*

COVID -19 Policy


By signing below you are acknowledging that during the time of the ongoing pandemic, if/when you enter the PCS office, you may be at increased risk of exposure to COVID-19. Also during this time, if you or PCS personnel are exposed to COVID-19, we may need to give information about you to the CRIT on campus. PCS will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for your visits. 

COVID-19 Policy *

Psychological Counseling Services Informed Consent

By signing this form, I have read, understand, and agree to the information provided above regarding telemental health services, consent to treatment, and the provisions listed PCS Informed Consent:


Use your mouse or finger to draw your signature above
Powered by Formstack Create your own form