THIS IS NOT AN EMERGENCY CRISIS FORM. IF YOU NEED TO SPEAK TO SOMEONE IMMEDIATELY, PLEASE CALL (855) 364-7981.



A therapist will contact you via email to schedule your appointment. Please respond as quickly as possible to move along the process of other students.

Therapy Request Form

Date of Submission*
Name*
Date of Birth*
Gender

Personal Contact Information

Home Address*
Address for Students outside of the U.S.
Prefered Method for Therapy*
Emergency Contact*
Address*
Address for Students outside of the U.S. - Copy

Medical Information

Psychotherapy Information

Have you ever participated in psychotherapy or counseling before?
Have you ever been hospitalized for mental health reasons?*
Are you currently experiencing any thoughts/plans of suicide? *
Have you in the past experienced any thoughts of suicide?*
Availability
Availability
  9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays

Student Information and Consent for Tele-Therapy

Client Information and Consent for CalArts Counseling Services

Telemental Health Services

CalArts Counseling services primarily offers traditional in-person, face-to-face counseling sessions.  However, telemental health services are available when it is deemed appropriate and necessary. 

In California, “telehealth” is defined as a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient and provider are at two different sites.


INFORMATION ABOUT TELEMENTAL HEALTH SERVICES AT CALARTS:

  • Telemental health services include the practice of psychotherapy delivery, diagnosis, consultation, treatment, transfer of data, and education using interactive audio, video, or data communications. If one form of technology fails in the course of the teletherapy session, an alternative form of communication may be utilized by your counselor (ex. Cell phone).
  • You have the right to withhold or withdraw your consent for telemental health services at any time without affecting your right for future care or treatment, nor risking the loss or withdrawal of any other service benefits to which you would otherwise be entitled.  
  • The laws that protect the confidentiality of my personal information in a face-to-face counseling setting also apply to teletherapy. As such, the information disclosed by me during the course of my sessions is generally confidential. The dissemination of any personally identifiable images or information from the teletherapy interaction to other entities shall not occur without my written consent except in the case of mandatory or permissive exceptions to confidentiality. Such exceptions include, but are not limited to:
    • suspected child, elder, and/or dependent adult abuse; 
    • expressed threat of violence towards an ascertainable victim;
    • expressed threat to harm or kill self; and
    • court subpoena.
  • There are potential risks and benefits associated with any form of psychotherapy, including telemental health services.  Despite the efforts of your counselor, your condition may not improve, and in some cases may get worse. 
  • Telemental health services may not be appropriate if you are experiencing a crisis or having active suicidal or homicidal thoughts. 
  • If a life-threatening crisis should occur, you must agree to contact CalArts Crisis Counseling Line at 855-364-7981; the National Suicide Prevention Lifeline at 1 (800) 273-8255; call 911, or go to your nearest hospital emergency department.
  • CalArts' counselors follow the laws and regulations of the State of California Board of Psychology and the Board of Behavioral Services.  Therefore, psychotherapy treatment, including telemental health services shall only take place in the State of California.  Both the counselor and client must be physically in the State of California to engage in telemental health. 
  • You must inform your counselor of the location in which you will consistently be during your sessions and inform them of any location changes.
  • If your counselor believes you would be better served by another form of psychotherapeutic services (e.g. face-to-face services), you will be referred to a counselor or resource who can provide such services in your area.
  • To participate in telemental health services, you will need a high-speed internet connection, a computer/laptop or device with speakers or headphones and a camera for video conferencing.
  • When receiving telemental health services, you must be in a private location where you will not be overheard or interrupted. CalArts will not be responsible for any breaches of confidentiality that occur due to your selected location or information heard by others who may be in the vicinity.
  • You agree to not record any telemental health session with any device.  
  • Despite reasonable efforts on the part of your counselor, there are risks and consequences from telemental health services, including, but not limited to, the possibility that transmission of your services could be disrupted or distorted by technical failures, or be interrupted by unauthorized persons.
  • It is recommended that you always have a phone available and that your counselor has your phone number.
  • If you get disconnected during your telemental health session; restart the session. If you are unable to reconnect within five minutes; your counselor will call you via phone. 
  • Email contacts are not considered confidential.  Thus, email contacts will be limited and brief.
  • Telemental health services are delivered via third-party platforms, such as Zoom Health that are contracted through CalArts Student Health Center. These software-based platforms are fully encrypted and secure and meet all the requirements of the Health Insurance Portability and Accountability Act (HIPAA). 
  • You may be asked to complete forms online prior to a telemental health session.  Please understand that your counselor may not have access to, or preview, your completed forms until the day of your appointment.  
  • If your counselor is concerned about you or loses contact with you (e.g., you fail to show for a scheduled telemental health session, you don’t respond to our follow-up attempts, etc.) they may contact you by phone to check on your well-being.  In addition, if they are uncertain of your safety or the safety of others, your counselor may contact someone from your list of contacts or your local emergency agency.

Your signature below indicates that you have read and understand this Consent form for telemental health services and consent to treatment and the provisions listed above.

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