Counseling Services Intake Application

Click here for Counseling Office Client Information.

Date:

UA-PTC Student ID Number:

First Name:

Last Name:

Preferred/Nickname (if applicable):

UA-PTC Site Attending:

Main Campus - North Little Rock

Little Rock-South

Aerospace Technology Center

Online

PERSONAL INFORMATION

Address:

City:

State:

Zip:

Phone/Cell Number:

UA-PTC Student E-mail:

How may we contact you?

UA-PTC Student E-mail

Phone/Cell

Alternate Phone - If this option is best, please select other and type the alternate phone number in the field.

Other...

Race/Ethnicity:

Self-Identify (please specify):

Gender:

Age:

Date of Birth:

Sexual Orientation:

Bisexual

Heterosexual

Lesbian/Gay

Questioning Self-Identify (please specify by selecting the other option and typing in your answer)

Other...

Major:

Are you Currently Employed?

Yes

How did you learn about counseling services?

Faculty/Staff member

Website

New Student Orientation

Walk-by Office

Friend

Other...

What are your goals for counseling (i.e., what do you want to occur as a result of counseling)? Please be as specific as possible.

Have you had any serious illness or injuries in Your life? If yes, please list. If no, type no:

Has there been a death of anyone close to you in the last five years? If yes, who? If no, type no.

How many people can you really count on right now, for emotional support?

Do you have the desire or need to harm yourself through:

cutting

burning

severing

inserting

hitting

constricting

picking

Other...

EMERGENCY CONTACT INFORMATION

Name:

Relationship:

Address:

Phone/Cell Number:

CONFIDENTIALITY POLICY

Confidentiality is an ethical standard that protects clients from the disclosure of information without their consent. Client contacts with the Counseling Office are confidential. We will not provide information about clients to friends, partners, faculty, parents, employers or anyone else outside of the Counseling Office Staff. Information may be exchanged between the UA-PTC Counseling Office & Disability Office, without requiring client consent, when those offices are providing services for the same client.

The Counseling Office will release information from counseling sessions to third parties only at the written request of the client. The “Authorization to Release Professional Information” form, signed by the client and a witness, will be used for that purpose. The client must give informed consent and therefore his/her counselor will discuss, prior to release, the information to be released, to whom, and for what purpose. The client will also be advised about the possible effects of disclosure.

Disclaimer: At any point that you may become suicidal, I will provide you with resources and or contact your emergency contact listed with UA-PTC.

Exceptions

When the Counseling Office believes that a client poses a clear and present danger of harm to himself/herself and/or others (verbal threat, action, or possession of a weapon or prohibited device), the Counseling Office may selectively release information, without the client’s consent, to aid in the care and protection of the client and/or endangerment of others.
When the Counseling Office has reasonable cause to suspect that a child (a person under 18 years of age) has been subjected to child maltreatment, which may involve abuse, sexual abuse, neglect, sexual exploitation or abandonment as defined by Arkansas Law, the Counseling Office, may selectively release information, without the client’s consent, to aid in the care and protection of a child. The Counseling Office is further required by Arkansas Law to report this information to the Department of Human Services.
When the Counseling Office has reasonable cause to suspect that an adult (a person 18 years of age or older) through abuse or neglect, is in imminent risk of death, or bodily harm and does not comprehend the nature and consequence of remaining in that situation or condition, then the Counseling Office is required to report this situation to the Arkansas Department of Human Services.

Type your initials:

Typing your initials confirms that you acknowledge and understand the confidentiality policy and exceptions above.

INFORMED CONSENT

I have voluntarily decided to seek personal counseling from the UA-PTC Counseling Office. I understand the following points about the treatment I will receive:

1. The treatment that I receive is considered confidential. I have been informed about the exceptions to confidentiality and presented with a full copy of the UA-PTC Counseling Office confidentiality policy.

2. Services are provided by staff members who are licensed counselors. Staff member credentials are kept on file and I may request to view those of my counselor.

3. The staff member who provides my personal counseling will offer treatment that is within the scope of his/her competence to provide.

4. Treatment will be based upon the particular issues, concerns, or problems which the staff member and I agree to work on.

5. Treatment goals are therapeutic in nature.

6. The treatment will consist of methods (strategies, techniques, and interventions) that are generally accepted in the mental health field as appropriate for the problems that I present. When there are limitations or foreseeable harm that could occur with a specific method, the staff member will explain them to me.

7. The staff member believes the proposed treatment can improve my condition and enable me to achieve my goals but he/she cannot guarantee the results.

8. There is no direct charge or cost for treatment services.

9. I, as the client, will not be forced to continue with the proposed treatment. I can choose to discontinue my personal counseling at any time.

10. I have been presented with the “UA-PTC Counseling Office Client Information” sheet that defines other pertinent information about practices and procedures.

Upon consideration of the information presented to me, I authorize the staff member to provide me with personal counseling and to use the methods that he/she believes clinically appropriate. I make this decision to accept the proposed treatment knowingly, voluntarily, and without coercion.

Student Signature:

I understand that typing my full name in this box constitutes a legal signature confirming that I have voluntarily decided to seek personal counseling from the UA-PTC Counseling Office and I understand the above information.