3-Step Application for Psychological Services at MPC

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This information is confidential and it will be seen only by Student Health Services Staff. This is a quick and easy 3-Step Process.

If you are in CRISIS and need to speak to someone immediately, please call the 24/7 Suicide & Crisis Lifeline at 9-8-8 or text COURAGE to 741-741.

For any EMERGENCIES, call 9-1-1

Email *

Today's Date: *

YYYY

First and Last Name *

Student ID# *

Pronouns: *

Which semester are you seeking therapy services for? *

FALL (up to 8 sessions)

SPRING (up to 8 sessions)

SUMMER (up to 5 sessions)

Reason for seeking therapy? *

Address: *

Cell# *

Work#

Home#

Best Phone number to reach you: *

Age *

Date of Birth *

YYYY

Gender *

Male

Female

Non-binary

Other

Ethnicity *

Hispanic

White

Asian

Filipino

Native American

Multi-ethnicity

Pacific Islander

African American

Unknown/decline to state

Relationship status: *

Single

Partnered

Married

Separated

Divorced

Widowed

Do any of the following apply to you (check all that apply)

I identify as having a disability (and/or are you a part of the Access Resource Center)

I am undocumented or part of the dreamer community (and/or are you a part of the Undocumented Resource Center)

I am a current or former foster youth (and/or a part of the NextUp program)

I am a veteran or active duty military (and/or are you a part of the Veterans Resource Center)

I identify as part of the LGBTQIA+ community

I am a first generation college student (and/or are you a part of EOPS/TRIO)

I am a single parent ( and/or part of the CARE & CalWORKS program)

Prefer not to answer

None of the above

May we identify ourselves and the purpose of our call? *

Yes

May we contact you via email for appointment information? *

Yes

Email address:

*email is not a secure form of communication, therefore confidentiality cannot be assured.*

Are you interested in Group, Couples or Individual Therapy? *

Group therapy

Couples therapy

Individual therapy

All the above

Required

Do you prefer in-person or online therapy? *

In-person therapy at MPC

Online therapy

Either

Are you currently working with a mental health provider? *

Yes

Have you received psychological services from MPC before?

If yes, when and with whom? *

If available, would you like to request a specific therapist?

Please check the times below that work best for your schedule (Psy office hours M-F 8am-5pm)

8am-8:50am

9am-950am

10am-10:50am

11am-11:50am

12pm-12:50pm

1pm-1:50pm

2pm-2:50pm

3pm-350pm

4pm-4:50pm

MONDAY

Please check the times below that work best for your schedule (Psy office hours M-F 8am-5pm)

8am-8:50am

9am-950am

10am-10:50am

11am-11:50am

12pm-12:50pm

1pm-1:50pm

2pm-2:50pm

3pm-350pm

4pm-4:50pm

TUESDAY

Please check the times below that work best for your schedule (Psy office hours M-F 8am-5pm)

8am-8:50am

9am-950am

10am-10:50am

11am-11:50am

12pm-12:50pm

1pm-1:50pm

2pm-2:50pm

3pm-350pm

4pm-4:50pm

WEDNESDAY

Please check the times below that work best for your schedule (Psy office hours M-F 8am-5pm)

8am-8:50am

9am-950am

10am-10:50am

11am-11:50am

12pm-12:50pm

1pm-1:50pm

2pm-2:50pm

3pm-350pm

4pm-4:50pm

THURSDAY

Please check the times below that work best for your schedule (Psy office hours M-F 8am-5pm)

8am-8:50am

9am-950am

10am-10:50am

11am-11:50am

12pm-12:50pm

1pm-1:50pm

2pm-2:50pm

3pm-350pm

4pm-4:50pm

FRIDAY

I acknowledge that I have been offered and/or received a copy of the Notice of Privacy Practices (HIPAA)

(type name below to sign)

CANCEL POLICY: Please notify your Therapist or Student Health Services at 831-646-4017 at least 24 HOURS in advance if you need to cancel your scheduled appointment. Late cancellations or no-shows affect other students in need of services and will result in your future appointments being scheduled only after our current waitlist requests have been fulfilled. Please contact us if you have any questions regarding this policy.

(type full name below to acknowledge)

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