Forms

• Request to Release Records
• Authorization to Release Information
• Authorization to Disclose Mental Health Information
• Fee Waiver Request
• Minor Consent Form

• Student Health & Counseling Service - Student Feedback
• Counseling Feedback
• Counseling Group Feedback

• Health History Form
• Immunization Medical Exemption Request Form
• Family PACT
• Patient Complaint Form

• Counseling Informed Consent
• Safety planning resources:
  • Strength-Based Safety Plan (Adapted by Dr. David Emmert)
  • Personal Crisis Plan (Wellness Recovery Action Plan from Dr. Mary Ellen Copeland )
  • SAGE Response to a Psychosocial Crisis (developed by Oakland Power Projects of Critical Resistance )
  • Sample Advance Mental Health Directive

Psychiatry

• Authorization to Disclose Mental Health Information
• Informed Consent to Receive Psychiatric Treatment
• ADHD Treatment Policy
• ADHD Medication and Controlled Substance Agreement
• ADHD Treatment Instructions
• Documentation of Previous ADHD Treatment
• Diagnostic Interview for ADHD in adults (DIVA) 2.0
• ADHD Assessment Process and Referrals

If you have any questions, please call (510) 885-3735 or email shcs@csueastbay.edu.