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Student Care Services Intake Form


Intake and Informed Consent

In an effort to identify resources that might prove useful to you, you are asked to complete the following intake form. This intake information is intended to help you maintain success at the University by identifying current concerns you might be experiencing and connecting you with resources to help address those concerns.

 
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Additional Information

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Questions

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I am currently experiencing concerns in the following areas
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I am a transfer student
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I am receiving or have applied for services through Student Accessibility Services
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There are several resources that are available to you as a UCF student. Please check if you would like additional information on the following:
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I am currently working with a psychiatrist, counselor or other health care provider at UCF/local community:
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Acknowledgement The information collected through this intake form is used to better understand what brings you to the SCS office, what stressors you may be experiencing, and how best the SCS Care Managers can support you. 1.) By typing my name below, I understand that information that I or others share with Student Care Services Care Manager does not fall under the same confidentiality levels of a health care provider, psychotherapist or counselor. The services and work of Student Care Services fall under Family Educational Rights and Privacy Act (FERPA). 2.) Student Care Services staff take seriously their role to foster a safe campus for you and for others, which means that there may be certain limits to the privacy statement above: If a staff member has reason to believe that I am in danger or significant physical or psychological deterioration as a result of being unwilling or unable to follow treatment recommendations, he/she may contact a family member or another person who can help provide protection/ assistance. If there is evidence of clear and imminent danger of harm to myself and/or others, a staff member may report this information to authorities responsible for ensuring safety or other persons with the goal of defusing the danger and providing help. If there is information regarding the abuse, neglect, or exploitation of a child, elder, or dependent adult. A court order can require UCF to release information contained in my records or require a staff member to testify in a court hearing. Under Federal guidelines, SCS staff members must report or disclose information to University Officials when I make them aware of crimes impacting me; and/or other students and the university; These typically fall under two Federal mandates: Clery Act: criminal offenses (homicide, sexual offense, robbery, aggravated assault, burglary, motor vehicle theft, arson, dating violence, domestic violence, and stalking); hate or bias crimes and arrests/ referrals for disciplinary actions (weapons, drug and liquor law violations) Title IX: sexual offenses, including sexual violence, sexual harassment, stalking, domestic violence, intimate partner violence I understand that the Case Manager may be in contact with other University offices regarding my academic performance or other identified concern should it become necessary.
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Submission