Counseling Request Form

1
Name of Student* This field is required.
First Name
Last Name
2
Student LOLA#
3
Student Email* This field is required.
example@example.com
4
Student Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Student Phone#* This field is required.
Please enter a valid phone number.
6
Which campus is the individual needing/requesting services located on?
Abbeville
Crowley
Franklin
Lafayette
Morgan City
New Iberia
Opelousas
St. Martinville
Ville Platte
7
Reason for Referral* This field is required.
Adjustment
Anger Management
Anxiety
Depression
Family Conflict
Grief - Loss/Death
Physical/Emotional Trauma
Relational Issues
8
What type of services are you or the individual needing services interested in?
Texting Based Counseling
Telehealth Counseling - Virtual
In-Person Counseling Sessions
Any Service
9
Additional Comments
Huge
Large
Normal
Small
Ok
Ok
10
Has the individual requesting/needing services had suicidal thoughts?* This field is required.
Yes
No
Maybe
Sometimes
I Don't Know
11
Does the individual requesting/needing services need additional services such a food, housing assistance, etc?* This field is required.
Yes
No
Maybe
12
Are you completing this form on the behalf of someone else?* This field is required.
YESNO
13
If you are completing this form on the behalf of someone else, please provide your name.
First Name
Last Name
14
Acknowledgement of Consent Signature I, the undersigned, hereby acknowledge and consent to receive counseling services through a referral from South Louisiana Community College (SoLAcc) to an external counseling provider. These services may include individual therapy, group therapy, or other related counseling activities. I understand that the counseling services are being provided by an outside, licensed mental health professional or agency and not directly by the College. I am aware that the College is referring me for support, but the provider will be responsible for the counseling process including scheduling and therapy services. As long as the student is currently enrolled at the College, there are no fees. Upon graduation, should the student so choose to continue services with the external counseling provider, fees may be applicable. By signing this form, I confirm that I understand the nature of the counseling services and voluntarily give my consent to receive services from the external counselor or agency referred by SoLAcc.
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