DATE: _______________ Fresno City College Madera Center Reedley College Clovis Community College S.C.C.C.D. REQUEST FOR PSYCHOLOGICAL SERVICES FORM CONFIDENTIALITY: Everything on this form is treated as CONFIDENTIAL Information. Psychological Services staff are mandated reporters, so information related to suicidal and/or homicidal thoughts, child neglect and/or sexual abuse, elder abuse, or dependent adult abuse or neglect may result in staff contacting the proper authorities. By initialing here, you are stating that you understand the limits of confidentiality. _______________ Phone (primary) __________________ Ok to call? Yes No Is it OK to leave voice mail? Yes No Phone (secondary) __________________ Ok to call? Yes No Is it OK to leave voic ? Yes No Do you prefer to be contacted by or Phone ? _____________________________________ _____________________________________________________________________________________________ Date of Birth: _____________________ Birthplace: __________________________________ Male: _______ Female: _______ Other: _____________ Age: _______ Preferred Language _______________________ Ethnicity : African-American Asian Biracial Caucasian Latino/aHispanic Native-American Other Marital Status : Never Married Live with Significant Other Married Separated Divorced Widowed Live with Parent ? YesNo ______________________________________________________________________________________________________ Revised 02/04/16 Monday Tuesday Wednesday Thursday Friday *List ALL Your Available times between 8-4 Mon,Thr, Fri 8-6 Tues, Wed Please Complete Compassion. Action. Change. Initials STUDENT ID : ________________ First visit to Psychological Services? YesNo If no, please indicate date of last visit: Year _____ Fall/Spring Are you having suicidal thoughts? YesNo Are you having thoughts of causing serious bodily injury AND/OR of killing another person? YesNo ___________________________________________________________________________________ Last NameFirst NameMIMaiden Name __________________________________________________________________________________ Street ( Best address to send correspondence, if needed ) City, StateZip Code

DATE: _______________ Fresno City College Madera Center Reedley College Clovis Community College S.C.C.C.D. REQUEST FOR PSYCHOLOGICAL SERVICES FORM Compassion. Action. Change. STUDENT ID : ________________ Who referred you to Psychological Services? 1 Instructor 2 Friend 3 Self 4 Family 5 Counselor 6 Coordinator 7 Dean 8 Vice President 9 Nurse 10 District Police 11 FCC Website 12 Other ___________________________ Name of Person who referred you: __________________________________________________ Please circle which services interest you (circle all that apply): Individual Therapy Group Therapy Both Emergency Contact Person _____________________ Relationship _____________________________ Phone Number __________________ Please initial for permission to call emergency contact ____________ IMPORTANT CLINIC POLICIES: The Psychological Services Department at SCCCD, by the use of a brief therapy model, strives to accommodate the needs of our students. Before initiating services, every student must submit a services request and mental health screening form, and then schedule and attend a mental health screening appointment with one of our clinicians. Mental health screening appointments are minutes in length; the purpose of these appointments is primarily to determine whether treatment is most appropriate through our department or another treatment provider. Please be advised that based on the clinician’s judgment, if it is in the best interest of the student’s mental health needs, a referral to a community (off-campus) treatment provider will be made. By signing below you acknowledge that you have read and understand your clinician's role as a mandated reporter and the limits of confidentiality. You also acknowledge that you understand that the purpose of a mental health screening appointment is to determine whether our services OR community referrals are most likely appropriate based on clinical judgment of your current treatment needs. You also acknowledge that these brief screening appointments are only minutes long, and that if you do not call within 24 hours to reschedule, are late, or do not attend your scheduled mental health screening appointment, you will be required to resubmit a service request form and mental health screening form. Client signature ___________________________________________Date _________________

DATE: _______________ Fresno City College Madera Center Reedley College Clovis Community College S.C.C.C.D. MENTAL HEALTH SCREENING FORM Welcome to Psychological Services! Please complete the entire mental health screening form so that we can determine how to best meet your needs. You MUST complete the mental health screening form and submit this along with your services request form to the Psychological Services front desk clinician before your mental health screening appointment will be scheduled. CONFIDENTIALITY: Everything on this form is treated as CONFIDENTIAL Information. Psychological Services staff are mandated reporters, so information related to suicidal and/or homicidal thoughts, child neglect and/or sexual abuse, elder abuse, or dependent adult abuse or neglect may result in staff contacting the proper authorities. By initialing here, you are stating that you understand the limits of confidentiality. _______________ Compassion. Action. Change. STUDENT ID : ________________ 1. Briefly describe what your reasons for seeking therapy are at this time: _________________________________________________________________________________________________________________ 1a. Rate your current level of distress : ____ Minimal ____ Mild ____ Moderate ____ Severe 2. How long have these difficulties been occurring? ____________________________________________ 3. Have you received psychological treatment (psychotherapy or medication treatment) in the past? Please circle one: YES or NO If yes, complete the following: 3a. When did you receive treatment? __________________________________________________ 3b. How long did treatment last? _____________________________________________________ 3c. What was being treated at that time, and what was the treatment (medication/psychotherapy)? __________________________________________________________________________________ ___________________________________________________________________________________ Last NameFirst NameMIMaiden Name Physician Name & Phone Number: _____________________________________________________________________________________ Psychiatrist (if applicable) Name & Phone Number: _____________________________________________________________________________________

DATE: _______________ Fresno City College Madera Center Reedley College Clovis Community College S.C.C.C.D. MENTAL HEALTH SCREENING FORM Dosage Date Started Purpose Medication Name What prescribed or over-the-counter medications are you currently taking? Compassion. Action. Change. STUDENT ID : ________________ 4. Have you ever been hospitalized for psychiatric reasons in the past? YES or NO If yes, complete the following: 4a. What year(s) were you hospitalized? __________________________________________________ 4b. How long were each of your hospital stays? __________________________________________________________________________________ 4c. Please list the reasons for hospitalization(s): __________________________________________________________________________________ __________________________________________________________________________________ By signing below you acknowledge that you have read and understand your clinician's role as a mandated reporter and the limits of confidentiality. You also acknowledge that you understand that the purpose of a mental health screening appointment is to determine whether our services OR community referrals are most likely appropriate based on the clinician’s judgment of your current treatment needs. You also acknowledge that these brief screening appointments are only minutes long, and that if you do not call within 24 hours to reschedule, are late, or do not attend your scheduled mental health screening appointment, you will be required to resubmit a service request form and mental health screening form. Client signature ___________________________________________Date _________________