UAF SHCC Telehealth Intake & Registration Form

Student Health and Counseling Center

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | 907-474-7043, telephone 907-474-5777, fax | www.uaf.edu/chc
UAF SHCC Patient Registration Form for Counseling Services

Thank you so much for giving us the opportunity to support you! We appreciate the information you share on this form. It helps your counselor know how to contact you as well as get to know you.
Name*

First NameLast Name
UA Identification Number
Date of Birth*

MonthDayYear
Date
Age
Gender
Pronouns
Preferred Name
Describe your ethnicity/race
Please describe other aspects of your identity you would like your therapist to know about.
What is the best telephone with which to contact you?*
10 digit phone number include area code

Using this telephone number, do you give permission for UAF SHCC staff to:*

	Yes	No
call you?
leave a voicemail for you?

What is the best email address with which to contact you?*
[email protected]
Can UAF SHCC Staff use this email address to contact you?*

YesNo
What is your current, physical address? If you live on-campus, include the name of your residence hall and room/apt #. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What type of counseling services are you seeking?

	Yes	No	Unsure
Individual therapy
Couples therapy
Group therapy
Check-in with a counselor for help or more information about services
Consultation about a concern I have or someone else is experiencing
Help connecting to other resources

What concerns are you wanting to address in counseling?
What has been helping you cope with or reduce the impact of the concerns you want address?
What are your hopes for counseling?

Please indicate if you have ever in the past or present:

	Yes	No	Unsure
attended outpatient therapy for mental health concerns?
been hospitalized for mental health concerns?
sought treatment for substance abuse?
struggled with thoughts about ending your life?
attempted to end your life?
engaged in self-harming behaviors?
struggled with an eating concern?
experienced difficulty with your vision?
experienced difficulty with your hearing?
experienced difficulty with mobility?

How is your physical health?
Who is your primary care physician?
What is your physician's contact phone number? please enter 10 digit #
phone number
What is your physician's address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any prescription or over-the-counter medications you use currently.
Please list any supplements you use currently.
What is your academic area of study?
Please describe how you are feeling about your academic progress.
Please indicate if you are working currently and what kind of work you perform.
Please describe any legal concerns you have experienced in the past or present.
Please describe any hobbies, special interests, or strengths you have.
If you have other information you would like to share with your counselor, please feel free to expand upon it.
How did you learn about UAF SHCC services? We are very happy you contacted us!
Date of signature*

MonthDayYear
Date
Signature*

Clear
Three Emergency Contacts for Telehealth Psychotherapy and Counseling Services

Please provide us with the names and contact information of three trusted people your counselor can contact if there is a technoogy failure or concer about your health and well-being.
Contact #1's Name*

First NameLast Name
How is this person related you ?*
Contact #1's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #1's Telephone Number*

Area CodePhone Number
Contact #1's Email
[email protected]
Contact #2's Name*

First NameLast Name
How is this person related you ?*
Contact #2's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #2's Telephone Number*

Area CodePhone Number
Contact #2's email
[email protected]
Contact #3's Name*

First NameLast Name
How is this person related you ?*
Contact #3's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #3 Telephone Number*

Area CodePhone Number
Contact #3's Email
[email protected]
By signing this form,

I hereby authorize the UAF STUDENT HEALTH AND COUNSELING CENTER to contact the three people listed on this form in the event my counselor has concerns about my health and well-being and/or is unable to contact me due to technology failure.

I understand that I may revoke this authorization at any time in writing. The revocation will not change any action taken between the date of the original authorization and the date of the revocation is received by UAF SHCC.
My authorization is given voluntarily for the above-stated release of information and will remain in effect for ONE YEAR from the date of signature OR through
Date
I agree to terms & conditions

check box if you agree
Date of Signature*

MonthDayYear
Date
Signature*

Clear
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Student Health and Counseling Center

UAF SHCC Patient Registration Form for Counseling Services