Request an appointment form

Student contact information

First name *

Last name *

Address *

City *

State *

Zip *

Phone *

Email *

Student ID# *

Date of birth *

Gender

Male

Female

Other

Presenting concern

What is your concern or reason for contacting us? *

What times work best for you? *

Select all that apply.

Morning

Afternoon

Evening

Which campus works best for you? *

SSC Akron

Main campus

Is there a specific date that work best for you?

Is there a specific time that work best for you?

Have you been to a mental health provider before? *

Yes

No

If yes, when and where?

Are you having any current or recent thoughts about harming/killing yourself or someone else? *

Yes

No

If yes:

Please call or text 988 immediately or visit https://988lifeline.org/talk-to-someone-now/.

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.

Initial *

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.

Initial *

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.

Initial *

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.

Initial *

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.

Initial *

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.

Initial *

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.

Initial *

Release of information

With my signature I hereby grant the above initialed consents.

Signature *

Use cursor to write full name.

Reset Signature

Signature is required.

reCAPTCHA is required.

Student contact information

Presenting concern

Consent for services

Consent for follow-up

Privacy disclosure

Release of information

Ready to learn more?