Confidential Counseling Self-Referral Form

Taft College  >  Admissions  >  Confidential Counseling Self-Referral Form

Confidential Counseling Self-Referral Form

  • Student Information

  • Please tell us how to contact you.

  • Emergency Contact

  • Name of Emergency Contact
  • Relationship to Emergency Contact.
  • Phone Number of Emergency Contact.
    Check this box if you give permission to contact this individual
  • Please explain your reason for requesting services.
    Please choose Yes or No.
    Please choose Yes or No.
    Please choose Yes or No.
    Please check all that apply.

LIMITED CONFIDENTIALITY

Information shared with Wellness Center staff will be kept confidential except within a few specific circumstances. Wellness staff are mandated reporters. Information related to harm to self or others, child abuse, elder abuse, or dependent adult abuse will be shared with the appropriate authorities.