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Transferring care to Hazen Counseling Center

  • Parent Name: Parent Name:
  • Parent Phone Number: Parent Phone Number: - -
  • Student Name: Student Name: *
  • Student Date of Birth: Student Date of Birth: * / /
    Pick a date.
  • Student Phone Number: Student Phone Number: * - -
  • Is your student currently receiving mental health treatment at home?
    Is your student currently receiving mental health treatment at home?
  • If yes, what type of treatment?
    If yes, what type of treatment?
  • If your student is currently engaged in counseling and/or taking medication for a mental health concern, is the provider willing to continue treatment while your student is away at school?
    If your student is currently engaged in counseling and/or taking medication for a mental health concern, is the provider willing to continue treatment while your student is away at school?
  • Is your student interested in receiving services on campus at the Counseling Center? https://www2.brockport.edu/life/counseling-center/services/
    Is your student interested in receiving services on campus at the Counseling Center? https://www2.brockport.edu/life/counseling-center/services/

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350 New Campus Drive
Brockport, NY 14420