Transferring care to Hazen Counseling Center
Parent Name:
Parent Name:
First
Last
Parent Phone Number:
Parent Phone Number:
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Student Name:
Student Name:
*
First
Last
Student Date of Birth:
Student Date of Birth:
*
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MM
/
DD
YYYY
Student Phone Number:
Student Phone Number:
*
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Student Email:
*
Is your student currently receiving mental health treatment at home?
Is your student currently receiving mental health treatment at home?
Yes
No
If yes, what type of treatment?
If yes, what type of treatment?
Medication management by primary care physician
Medication management by psychiatrist
Individual counseling/therapy
Group counseling/therapy
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?
Yes
No
If your student is taking prescribed medication(s) for a mental health concern, please let us know what they are on and the dosage.
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/
Yes
No
Unsure
How can we help support your student's mental health and wellness at SUNY Brockport?
Additional Questions or comments:
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