Intake Form

We're Here for You.

Fill out the following intake form to begin your journey to help and health.

Name*
First Last
Suffix
Preferred First Name
Pronouns
Your Preferred Pronouns
Your Major / Program*
Your Year at RMCAD*
What Year?
Please enter a number from 0 to 100.
Your RMCAD Student ID
Modality*
Your Date of Birth*
MM slash DD slash YYYY
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your RMCAD Email*
Your Phone Number*
How did you hear about counseling at RMCAD?*
If you answered "Other" above, please share below.*
Emergency Contact
In case of an emergency (such as hospitalization, ER visit, suicide risk, or if the counselor is unable to reach you for an extended period), is there someone you give the Counseling Center permission to contact?
Name*
First Last Suffix
Relationship to You*
Contact Phone Number*
Alternate Phone Number
Additional Contact
- Add another contact
Name*
First Last Suffix
Relationship to You*
Contact Phone Number*
Alternate Phone Number
Additional Contact
- Add another contact
Name*
First Last Suffix
Relationship to You*
Contact Phone Number*
Alternate Phone Number
Personal Information
Relationship Status
(E.g. single, dating, married, divorced, long term partnership, etc.)
Living situation
(E.g. with parents, with roommates, alone)
Are there important cultural considerations surrounding your race, ethnicity, sexual orientation, gender identity, age, sex, ability, religious affiliation or other cultural factors that you think are important for your counselor to know or that may impact your counseling?
Are you a veteran?*
- Yes
- No
Have you received counseling services in the past?*
- Yes
- No
With whom were you counseled?
When were you counseled?
For how long were you counseled?
Have you received counceling at RMCAD?
- Yes
- No
Please list all the times you are available for counseling in Mountain Standard Time (MST).*
Are you seeking in person or virtual session?*
- In Person
- Virtual
Please briefly describe your reason(s) for seeking counseling
Please write any additional information you feel is important to add about you regarding counseling
Confidentiality
All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate.
EXCEPTIONS TO CONFIDENTIALITY:
- If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
- Colorado state law requires that staff of Counseling Services who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to county child protection services.
- A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a counselor to testify in a court hearing.
We appreciate prompt arrival for appointments. Please notify me if you will be late. Twenty-four hour notice of cancellation allows me to use the time for others.

There is no fee for counseling services. If you are referred off campus to health, mental health, or substance abuse professionals you are responsible for their charges.

If a student misses 2 sessions without prior notice/communication given to the counselor, they will no longer be eligible for sessions for the remainder of the term. This is because we have an ever-increasing waitlist of students needing a spot, and we want to be sure the counseling session spots that are taken are being utilized.

By submitting this informational counseling form it means you have read and understood the above information. You understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of you as a client of the RMCAD Counseling Services.