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  • Student Health & Counseling ServicesClose Left Navigation Menu
  • Hours of Operation
  • Immunization Requirements and Recommendations
  • Quick Links
  • About SHCS
    • Media
    • Meet the Staff
    • Strategic Plan
    • FAQ
    • Feedback Request
    • News
    • Emergency Preparedness
    • Emergency Health Care
  • List of Services
    • ADHD Treatment
    • Appointments
    • Counseling
    • Gender Affirming Care
    • Health Education
    • Immunizations
    • Laboratory
    • Men's Health
    • Mother's Room
    • Pharmacy
    • Psychiatry
    • Radiology
    • Sexual Health
    • Women's Health
  • Hayward Clinic
  • Concord Clinic
  • Counseling
    • Counseling Options
      • Individual Counseling
      • Crisis Support
      • Group Counseling
      • Self-Help Videos
      • Counselor in Housing
      • Counselor in SEAS
      • Couples Counseling
      • Confidential Advocate
      • Online Mental Health Screenings
    • Meet the Counseling Staff
    • Wellness Resources
      • Resources - Issues and Conditions
      • Resources - Communities
      • Off Campus Counseling Referral List
      • Free and Low-Cost Psychiatry Referrals
      • On Campus Resources
      • Covid-19 Tips and Resources
      • Social Justice and Wellness
      • Pleasant Activities
      • Wellness Reading List
      • Current Events Stress
    • Other Related Information
      • Scope of Services
      • Eligibility
      • Client Rights
      • Client Satisfaction Survey
      • Faculty & Staff Resources
      • Wellness Ambassadors
      • Students in Distress
      • Presentation Videos
      • Self-Care After a Loss
      • Request An Interview
      • Info for Parents & Family
      • Training Program
  • Mental Health Screening
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    • authorization-to-disclose-mental-health-information-form-edited.pdf
    • authorization-to-disclose-mental-health-information-form-edited1.pdf
  • hipaa Privacy Practices
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Forms

General
  • Request to Release Records
  • Authorization to Release Information
  • Authorization to Disclose Mental Health Information
  • Fee Waiver Request
  • Minor Consent Form
Feedback
  • Student Health & Counseling Service - Student Feedback
  • Counseling Feedback
  • Counseling Group Feedback
Medical
  • Health History Form
  • Immunization Medical Exemption Request Form
  • Family PACT
  • Patient Complaint Form
Counseling
  • 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.

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