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*
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.
- 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.
ATTENDANCE POLICY We appreciate prompt arrival for appointments. Please notify your counselor if you will be late. Twenty-four hour notice of cancellation allows your counselor to use that time for others. 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.

SCOPE OF PRACTICE RMCAD offers students short-term counseling services that may not be suitable for all students depending on their current needs and clinical presentation. At any time, the counselor reserves the right to end services and/or refer a client to a more suitable level or type of care based upon their clinical judgment.

COST OF SESSIONS There is no fee for counseling services at RMCAD. However, if you are referred to an external health, mental health, substance abuse, psychiatry, or other professional, you are responsible for their charges.

COLORADO MANDATORY DISCLOSURE INFORMATION Colorado law requires mental health providers to disclose certain information in writing during initial client contact, which is provided for you below:

Provider Information
Katherine Connolly LCSW, HAE-I
Licensed Clinical Social Worker
Human-Animal-Environment Interactions Certificate
University of Denver Graduate School of Social Work

Business Address

Rocky Mountain College of Art + Design: Health + Wellness Center
Address: 1600 Pierce St, Lakewood, CO 80214
Phone: 303-868-2206

Requirements for the LCSW To gain my LCSW, I completed my Masters of Social Work from a CSWE accredited institution, complete 3,360 supervised hours of post-graduate experience over the course of 2 years under a fully licensed LCSW (including 1,680 hours of direct client contact) while holding my SWC (Social Work Candidate) permit. I regularly engaged in direct supervision of my clinical work over these two years for a total of 96 supervision hours. I also passed the ASWB exam as well as the Colorado Jurisprudence Exam. To read more about the requirements for licensed clinical social workers in Colorado, please go to: https://dpo.colorado.gov/SocialWork.

Regulatory Agency Information

The practice of licensed clinical social workers in the field of psychotherapy is regulated by:
Colorado Department of Regulatory Agencies
1560 Broadway #1545, Denver, CO 80202
(303) 894-7855

Client Rights Counseling sessions with me are scheduled for 40 minutes in length and I primarily practice CBT, experiential, and narrative therapy in a person-centered approach. Duration of therapy is dependent on individual case presentation. Clients may be referred out for a more appropriate level or type of care based on clinical judgment at any time during the therapy treatment. As a client, you may seek a second opinion from another therapist or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the above licensing board. The information by the client during therapy sessions is legally confidential in the case of individuals licensed, certified, or registered pursuant to this article 245, except as provided in section 12-245-220 and except for certain legal exceptions that will be identified by myself should any such situation arise during therapy. A client’s records may not be maintained after seven years pursuant to section 12-245-226 (1)(a)(II)(A).

ACKNOWLEDGEMENT OF CONSENT TO SERVICES 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.

Intake Form

We're Here for You.

Emergency Contact

Personal Information

Confidentiality

EXCEPTIONS TO CONFIDENTIALITY:

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