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Detail

First Name of Person attending session

Last Name of Person attending session

Who is the appointment for?

Gender Identity

If not listed, how would you describe your Gender Identity?

Phone Type

Preferred Phone# of Person attending session

Preferred Email of Person attending session

Have you previously used the Faculty Staff Help Center's services?

Are you are already seeing someone here and want to make follow up appointments?

Current Therapist Name

Please Indicate where Stanford Employee works at Stanford

Preferred Form of Session

Preferred Days

Preferred Times

Who will attend the session?

Please share any information or requests, including If you need a disability-related accommodation (i.e. sign language interpreter, captioning, etc.) for your counseling appointment.

If you are a child/dependent, can you please tell us your age below?

Pronoun

How did you hear about us?

Job Classification of Employee

Race/Ethnicity

Clients Emergency Contact Phone #

Clients Emergency Contact Email Address

Clients Home Address

City

State

Zipcode

Parent or Guardian of Minor (If applicable, print minor’s name. This gives my consent for minor child/children to be seen at the FSHC)

Are you currently seeing an outside Therapist for mental health counseling

If you are an LPCH employee, please add your Birthdate to the box below.

If you are the child or spouse of an LPCH employee, please add your Birthdate to the box below

If you are the spouse or dependent of an LPCH employee, please add the LPCH employee full name to the box below

If you are the spouse or dependent of an LPCH employee, please add the LPCH employee birthday to the box below

Submit

STATEMENT OF UNDERSTANDING

I understand that the Faculty Staff Help Center (FSHC) provides free, confidential, short-term counseling to faculty and staff (including post docs and retirees) of Stanford University, Stanford Hospital, LPCH, and SLAC and members of their families through age 25. Counseling is provided to individuals, couples, families and work groups.

I understand that my eligibility for participation is contingent upon my status as an employee or family member of the above stated eligibility pool.

I understand that confidentiality is kept within the FSHC staff and no information will be released outside of the FSHC without my written consent EXCEPT IN THE FOLLOWING CIRCUMSTANCES: REASONABLE SUSPICION OF CHILD ABUSE; REASONABLE SUSPICION OF ELDER ABUSE; THREAT OF VIOLENCE TO SELF OR OTHERS.

I understand that my benefit is for up to 10 sessions of counseling. The first session is always an assessment of the issues and a decision will be made between client and clinician about next steps. The FSHC focus is on short-term problem recognition and resolution. If extended counseling is needed or the staff at the FSHC cannot meet the needs of the client, referrals will be made.

I understand that if I miss an appointment without calling to cancel, that appointment will count toward my 10 sessions.

I understand that there is no cost for the services of the FSHC and if referrals are made, the cost of those referrals will be my responsibility.

Informed Consent for Telehealth Consultations.

I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using secure video conferencing technology.

I understand that with telehealth:

1/ I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
2/ I have a right to confidentiality with regard to my EAP services and related communications via Telehealth under the same laws that protect the confidentiality of my information during in-person EAP services. The same mandatory and permissive exceptions to confidentiality outlined above also apply to my Telehealth services.
3/ There will be no recording of any of the online sessions by either party.
4/ I am responsible for using a location that is private and free from distractions or intrusions.
I am responsible for ensuring that my internet connection is private and secure.
6/ The risks associated with participating in Telehealth include, but are not limited to: Technical interruptions due to internet bandwidth and continuity Limited ability by the clinician to respond to emergencies
7/ The Counselor is required to verify my current location at the beginning of each Telehealth session.

By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

I understand that the FSHC is not an “on-call” clinic and that if I am having a psychiatric emergency, I will call 911 or go to the nearest emergency room.

Note: YOU MUST BE CURRENTLY LOCATED AT THE TIME OF YOUR APPOINTMENT WITHIN THE STATE OF CALIFORNIA TO RECEIVE SERVICES FROM THE STANFORD HELP CENTER. If you are out of state, you may send a message if you would like help with a referral.

This form and its client information are confidential and HIPAA compliant.

Parent or Guardian of Minor: If applicable, print minor’s name. This gives my consent for minor child/children to be seen at the FSHC.

If the parents of minor are divorced or separated, both parents will need to sign Consent.

Consent Full Name of Person attending session*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Consent Full Name (Spouse /Partner or Family Member)

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Consent Full Name (Additional Spouse /Partner or Family Member)

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Faculty Staff Help Center Request for
Counseling Services

If you or a loved one is experiencing a Mental Health emergency, call 911 or go to the nearest emergency room. If you need immediate emotional support call 988.

You must be located in the state of California to use our services. If you are an OUT-OF-STATE employee, please go to SupportLinc for mental health services.

This form and its client information are confidential and HIPAA compliant.