SWOSU Counseling Intake & Consent

SWOSU Counseling Intake & Consent

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EMERGENCY CONTACT & ACADEMIC INFORMATION
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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INFORMED CONSENTFOR FACE-TO-FACE AND TELEBEHAVIORAL HEALTHCOUNSELING SERVICES
Introduction

Welcome to Hilltop Health at Southwestern Oklahoma State University (SWOSU). Hilltop Health provides counseling and health services to currently enrolled SWOSU students. These services include both behavior health care and medical care. Medical visits are provided by a licensed medical provider practicing in accordance with Oklahoma law. This document explains important information about the services available to you, confidentiality, your rights and responsibilities, and consent for care. Please read it carefully before signing. Hilltop Health staff are available to answer any questions you may have, and you may request a copy for your records.

Eligibility and Services

Hilltop Health services are available to students currently enrolled at SWOSU in at least one (1) credit hour during the semester services are received. Behavioral health and medical services may include counseling, behavioral health assessment, crisis intervention, health assessment and treatment, acute illness and injuries, physical assessments, management of ongoing health concerns, preventive health services, testing, health education, medication-related services when available, telehealth, referrals to outside providers, and the ordering or prescribing of medications when clinically appropriate and permitted under Oklahoma law. Services are based on individual needs, provider availability, and the scope of services available through Hilltop Health. If your counseling or health needs are beyond the services available through Hilltop Health, staff will assist with an appropriate referral when possible. Behavioral health and medical services may be provided separately or together, depending on your needs and availability of the clinicians.

SWOSU employees and their dependents may be eligible for a limited number of counseling sessions through off-campus counseling providers. Please contact Human Resources for additional information regarding these services.

Confidentiality and Records

Hilltop Health values your privacy. Records related to counseling and health services are maintained separately from your general academic records and are protected in accordance with FERPA, applicable to Oklahoma law, and professional ethical requirements. Information about your care will not generally be shared outside of Hilltop Health without your permission.

Counselors adhere to the ethical standards of their profession and applicable state and federal laws. In some cases, counselors may consult with other Hilltop Health 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)

Hilltop Health may also work with appropriate university personnel, including the Behavioral Intervention Team (BIT), when additional support or coordination may benefit a student. With your permission, limited information such as attendance, general concerns, or recommendations for support may be shared. Detailed counseling session content will not be routinely shared.

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):
Telehealth Services

Behavioral health and medical services may be provided through telehealth when appropriate. Telehealth involves electronic communication and may have limitations, including technical problems, interruptions, and potential privacy concerns. You are responsible for participating in a reasonably private location when possible. You may request in-person services when available, and your provider may recommend in-person or outside services when telehealth is not appropriate for your needs.

· 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

Emergencies

Hilltop Health is not an emergency facility. If you are experiencing urgent concern during office hours, notify Hilltop Health staff immediately. For a life-threatening emergency, call 911. For an after-hours behavioral health crisis, contact SWOSU Campus Police at (580) 774-3111, call or text 988, or call 911.

Professional Services

Hilltop Health services are provided by appropriately licensed, credentialed, or supervised professionals practicing within their education, training, professional scope, and applicable Oklahoma law. This may include counseling and behavioral health professionals as well as medical and health professionals. Students may ask their provider about their credentials, licensure, or supervision at any time.

If you have concerns about your care that cannot be resolved with your provider, you may request to speak with the Director of Counseling & Health Services.

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 regulations, which govern their licenses. Counselors will furnish you with printed materials about the requirements of licensure if you 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

Attendance Policy / No Show Policy

Students are asked to provide at least 24 hours' notice when canceling or rescheduling an appointment whenever possible. Repeated missed appointments or late cancellations may affect future scheduling. Exceptions may be considered for illness, emergencies, or other circumstances.
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.
I voluntarily consent to receive behavioral health and medical services through SWOSU Hilltop Health, including evaluation, diagnosis, treatment, the ordering or prescribing of medications when clinically appropriate, telehealth when applicable, and referral to other providers when appropriate. I understand that I may ask questions about my care or discontinue services at any time.
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SWOSU Counseling Intake & Consent

EMERGENCY CONTACT & ACADEMIC INFORMATION

Academic / Career Information

COUNSELING & TREATMENT HISTORY

INFORMED CONSENTFOR FACE-TO-FACE AND TELEBEHAVIORAL HEALTHCOUNSELING SERVICES