• SWOSU Counseling Intake & Consent

    Share your contact details and counseling needs to get started.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Method of Contact*
  • Last Visit to PCP (Primary Care Physician)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you registered with Disability Services?*

  • EMERGENCY CONTACT & ACADEMIC INFORMATION

  • Format: (000) 000-0000.

  • Academic / Career Information

  • Classification*
  • Employment Status*

  • COUNSELING & TREATMENT HISTORY

  • Primary concern*
  • Is this your first time receiving counseling services?*
  • Was it helpful?
  • Relationship Status
  • In the past 30 days, have you worried about any of the following? Select all that apply.*
  • Would you like information about campus resources?
  • Have you served in the military?
  • Are you a parent/caregiver?

  • INFORMED CONSENTFOR FACE-TO-FACE AND TELEBEHAVIORAL HEALTHCOUNSELING SERVICES

  • Introduction
    Welcome to the Hilltop Health at Southwestern Oklahoma State University (SWOSU). This document provides important information about the counseling services available to you, including your rights and responsibilities as a client. This is a legal document. Please read it carefully before signing.

    Your counselor will be happy to answer any questions you may have. You may request a copy of this document for your records.

    Eligibility
    Counseling services are available to students who are currently enrolled at SWOSU. To be eligible, students must be enrolled in at least one (1) credit hour during the semester in which services are
    received.

    SWOSU employees and their dependents may be eligible for a limited number of sessions through offcampus counseling providers. Please contact Human Resources for additional information regarding theseservices.

    Confidentiality
    Your participation in counseling is confidential. Information shared during counseling sessions will not be disclosed to individuals or agencies outside of the Counseling Center without your written permission, except under specific circumstances required or permitted by law.
    Counselors adhere to the ethical standards of their profession and applicable state and federal laws. In some cases, counselors may consult with other Counseling Center staff to provide the best possible care. In these situations, only the minimum necessary information is shared.

    Limits of Confidentiality: Confidential information may be disclosed without your consent under the following circumstances:

    • If you present a risk of serious harm to yourself or another person
    • If there is suspected abuse or neglect of a minor, elderly person, or vulnerable adult (as required
    by law)
    • If your records are subpoenaed or otherwise required by a valid court order
    • If there is a medical emergency requiring immediate intervention
    • If disclosure is otherwise required or permitted by law

     

  • If someone referred you to the SWOSU Counseling Center (e.g., physician, instructor, advisor, RA) and they inquire, may we confirm that you did schedule an appointment?*

  • Expanded Informed Consent for Care Coordination (BIT Team)
    The Counseling Center may collaborate with a multidisciplinary team (e.g., the Behavioral Intervention Team, or BIT) to support student safety, well-being, and success. With your permission, limited information may be shared with appropriate university personnel on a need-to-know basis for the purpose
    of coordinating care and support.

    This may include information such as your engagement in services (e.g., attendance), general concerns related to safety or well-being, and recommendations for support or follow-up. This does not include
    detailed session content, psychotherapy notes, or specific personal disclosures, except when required by law or in situations involving risk of harm to yourself or others. The purpose of this coordination is to enhance support, promote student safety, and ensure an appropriate and timely response to concerns.

  • Client Choice (Please select one):*

  • Telebehavioral Health (Telehealth) Services
    Telehealth services may be offered as part of your care. These services use electronic communication technologies to provide counseling remotely. The Counseling Center uses secure platforms when available; however, there are inherent risks associated with electronic communication, including
    potential interruptions, technical failures, or unauthorized access. By participating in telehealth services, you acknowledge:
    • You are responsible for ensuring privacy in your environment
    • You understand the potential risks and limitations of telehealth
    • You have the right to request in-person services when available

     

    Counseling Services and Nature of Counseling
    The Counseling Center provides a range of services including initial intake and assessment, individual counseling (brief, solution-focused), crisis intervention, group counseling, psychoeducational
    programming and workshops, and referrals to community providers when appropriate. Counseling services are designed to be short-term and goal-oriented, with the length and frequency of services
    determined collaboratively between you and your counselor based on your individual needs, goals, and clinical recommendations.


    Counseling is a collaborative and voluntary process intended to help individuals address personal concerns, develop coping strategies, and work toward meaningful change. You may discontinue services at any time and are encouraged to discuss any questions or concerns with your counselor throughout the
    process. Counseling may involve exploring difficult or emotional topics, which can sometimes result in temporary discomfort. While many individuals benefit from counseling, specific outcomes cannot be guaranteed. The goal of counseling is to support you in developing skills and insight that you can
    continue to use beyond your time in services. If your needs extend beyond the scope of services offered, your counselor will assist you in connecting with appropriate community resources.

     

    Emergencies

    If you are experiencing an emergency during office hours, please notify Counseling Center staff immediately so that you may be seen as soon as possible. For after-hours emergencies, please contact: SWOSU Campus Police at (580).774.3111, 911 or 988.

     

    Statement of Professional Disclosure
    All counselors at the SWOSU Counseling Center are licensed professionals or supervised trainees working under appropriate supervision in accordance with state law. Clinical staff may include Licensed Professional Counselors (LPC) and Licensed Alcohol and Drug Counselors (LADC). All counselors are licensed by the Oklahoma State Board of Behavioral Health Licensure, which regulates professional
    standards and practices in the state of Oklahoma.

    If you have concerns about your care that cannot be resolved with your counselor, you may contact the licensing board or request to speak with the Director of Counseling Services. The licensing website is https://www.ok.gov/behavioralhealth/ where you can access the law and regulation, which govern their licenses. Counselors will furnish you with printed materials about the requirements of licensure if you so desire. You may contact (without giving your name) the Professional Counselor Licensing Division at:

    State Board of Behavioral Health Licensure (BBHL)
    3815 N. Santa Fe, Suite 110
    Oklahoma City, OK 73118
    Phone: (405). 522.3696
    Fax: (405). 522.3691

     

    Records
    The Counseling Center maintains electronic records of services provided, which may include intake information, session notes, assessments, treatment documentation, and other relevant records. These records are stored securely, maintained separately from academic records, and are accessible only to authorized Counseling Center staff. Records are maintained in accordance with applicable state and federal laws and regulations. You may request access to your records as permitted by applicable law.

     

    Attendance Policy / No Show Policy
    To ensure timely access to services for all students, you are expected to provide at least 24 hours’ notice if you need to cancel or reschedule an appointment. Missing an appointment without notice (a “no-show”)
    may result in the loss of a standing appointment time, and repeated no-shows may impact your ability to continue scheduling appointments at the Counseling Center. Exceptions may be made in cases of illness,
    emergency, or other extenuating circumstances. (*No Show is defined as not calling to cancel your appointment or calling to cancel with less than 24 hours’ notice.)

  • To protect your confidentiality, please indicate how we may contact you. Please be aware that an outside party could intercept information exchanged over e-mail.
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