College Telehealth Referral
Welcome to COLLEGE TELEHEALTH! We have partnered with your college to help support you in and beyond the classroom in a place that inspires you! Your college has pre-approved a designated number of online video counseling sessions as part of your enrollment.
We look forward to getting you started with our College Telehealth services with one of our licensed mental health clinicians. Let’s take this journey together to explore your goals, empower your confidence, and evolve into your authentic self!
✅STEP 1: Complete this quick form with your current information and location.
✅STEP 2: College Telehealth will review your information and reach out to you within 24 business hrs to confirm your request.
✅STEP 3: Based on your personal situation, you will be matched with a highly-skilled, professional, licensed therapist in your state who will reach out to your directly to schedule.
✅STEP 4: You will receive an email invitation to join our Client Portal with a personal dashboard. This will give you easy access to our electronic Intake Consent Forms and important information to get started with your Online Counselor.
If you need any assistance or have questions, please contact us directly. Thank you! We look forward to getting you started!
The College Telehealth Team
Virtual Main Office: 484.245.4455
Student Last Name
Student First Name
Student School ID Number
Date of Birth
City of Residence
State of Residence & Zip
How would you prefer we contact you to schedule?
Phone- Feel free to leave a voicemail.
Phone- I would prefer you do not leave a voicemail.
SELF REFERRAL- I am student seeking Telehealth counseling on my own or was referred by a faculty member .
COLLEGE REFERRAL- I am a faculty or staff member referring a student who is interested in counseling support.
Would you be interested in Spanish Telehealth services, if available? ¿Estarías interesado en los servicios en español, si estarían disponibles?
Please tell us briefly what is bringing you to counseling so we know how best to support you.
Check all that relate to you.
Feelings of Self Harm
Struggling with online classes
Dealing with COVID
Someone I care about has COVID
Ongoing Mental Health Difficulties
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This form was created inside of Virtual Counselor | College Telehealth.