Intake Form

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.