Request an appointment form | Stark State College - North Canton, Ohio
counseling support services

Request an appointment form

Your mental and emotional health is also important to us. If you need to talk with someone during this time, the College provides counseling and intervention services that can be accessed remotely. Please complete the following form to request an appointment.

Student contact information

Presenting concern

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Please contact 911, the Crisis Text Line by texting 4HOPE to 741-741 or the Suicide Prevention Lifeline at 1-800-273-TALK (8255) immediately. https://suicidepreventionlifeline.org/

Consent for services

I understand that the SSC Student Support Services Center offers services free of charge. I further understand that SSC Student Support Services counselors will utilize any, all, or a combination of customary procedures and consultation practices employed in behavioral health care including health assessment and some counseling therapy techniques. I understand that my consultation will be provided by a SSC Student Support Counselor who is licensed by the State of Ohio Counselor, Social Worker, Marriage and Family Therapist Board.

I understand that this is NOT counseling and understand the limitations to services provided by SCC Student Support Services Center. I understand that consultations with my psychiatrist, mental health professional, and/or physician, other SSC faculty/staff, family members, peers, and/or other resources involved in my care will be done only after I have given written or verbal consent.

I understand that the SSC Student Support Services Center will provide me with appropriate community referrals for counseling, case management, and psychiatric services as needed.

I understand that the SSC Student Support Services Center does not prescribe medications and will refer me appropriately to be assessed by a medical professional if medications are a recommendation for treatment.

I understand that confidentiality may be waived if 1) it is mandated by court order 2) suspected child/elder abuse and/or neglect, and 3) there is an expressed or significant concern of imminent risk of physically harming myself, another identified person, or an identified structure.

Consent for follow-up

I hereby give the SSC Student Support Services Center staff consent to contact me by phone, email, letter, or in person for scheduling purposes, assess current or impending needs, and provide referral and/or follow-up information.

Privacy disclosure

I understand that although all attempts to maintain privacy will be made, electronic communication (such as e-mail, text messages, voice over data calls, etc.) is not guaranteed to be secure.

Release of information

With my signature I hereby grant the above initialed consents.
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