BASICS student registration
Please complete and submit the pre-registration information below. Additionally you may submit payment using this form or pay later by phone or at Connections Counseling main clinic. After pre-registration, you will be contacted (initially by email, also by phone if necessary) to schedule your first individual session.
Mobile phone number
Home or other phone
Date of birth
BASICS completion deadline
Year in school
Campus address street
Campus address city
Campus address zip code
Have you completed CHOICES about alcohol group previously?
NO - referred directly to individual BASICS
YES - completed CHOICES at Connections
YES - completed CHOICES at Tellurian
Was marijuana also involved in this incident?
Dean of Students
Madison Police Dept
UW Police Dept
Other referral source
Name of referring individual
Referring individual email address
Ethnicity self-identification (voluntary)
Hispanic or Latino
White (Not Hispanic or Latino)
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Two or More Races listed above
Ethnicity not self-identified
Payment must be made before first session. Provide your VISA or MASTERCARD information to charge session cost of $200. Following registration and payment you will be contacted by Connections Counseling to schedule your first individual BASICS session. First contact will be by email. Payment may also be made by telephone (608-233-2100 x-0 Mon-Thur 9 am to 7 pm and Friday until 3 pm) or in person at Connections Counseling LLC, 5005 University Ave, Ste 100, Madison 53705.
Credit Card Type
Credit card expiration month
Credit card expiration year
CCV code on back of card
Billing name if not in your name
Billing zip code if not your campus address
Any addition information we should know? Include schedule preference (day of week, time of day)?
BASICS Client Rights and Informed Consent
PLEASE REVIEW AND AFFIRM YOUR UNDERSTANDING AND CONSENT BY CHECKBOX BELOW.
Individual BASICS ($200) is a prevention program for college students who may drink alcohol heavily and have experienced or are at risk for alcohol-related problems. Following a harm reduction approach, Individual BASICS aims to motivate you to reduce alcohol use in order to decrease the negative consequences of drinking.The program involves two one-on-one sessions (sessions scheduled two weeks apart) with a professional substance abuse counselor. In the sessions, you will have a structured opportunity to assess your individual risk and identify potential changes for the future, and is intended to reduce the potential harms that are associated with high-risk drinking.
I understand that all information shared with the therapists at Connections Counseling is confidential and no information will be released without my consent. If I am a University of Wisconsin Madison student, I understand Connections Counseling and UW-Madison have an established Memorandum of Understanding, allowing for my demographic, assessment and program compliance information to be disclosed between said parties. If I am an Edgewood College student, I understand Connections Counseling and Edgewood College have an established Memorandum of Understanding, allowing for my demographic, assessment and program compliance information to be disclosed between said parties. In all other circumstances, consent to release information is given through written authorization. I further understand there are specific and limited exceptions to this confidentiality: when a specific statutory exception applies or a duty to warn exists.Connections Counseling is a certified outpatient drug/alcohol and mental health clinic. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. However, the purpose of therapy is to alleviate problems and symptoms I present. I further understand it is the therapist’s responsibility to suggest alternative treatment modes and will assist in referrals when appropriate and necessary.If I have any questions regarding this consent form or about the services offered at Connections Counseling, I may discuss such with my therapist. Also available if requested, is a pamphlet explaining your rights and the grievance procedure available to you. Please ask your therapist or the office if you would like a copy.
I understand that I have the right to withdraw informed consent at any time in writing. Otherwise this consent will be valid for 15 months.
I may report any formal grievances to Clients Rights Specialist, Inc. Maria Hanson, JD at P.O. Box 14533 Madison, WI 53714-0533 or (608) 446-8957.
$200 BASICS session fee is required when scheduling initial Individual BASICS session Individuals are able to submit payment online, by phone or in person at main clinic's front desk (5005 University Ave Ste 100), if he/she does not have a credit card.
Failure to attend: If I do not show for the first Individual BASICS session or cancel with less than 24 hours notice; an $80 no/show fee will be retained and balance of payment refunded. I will be required to make another appointment at full price. If I do not show for the second and final session of Individual BASICS or cancel with less than 24 hours notice; an $80 fee will be due on the day of service of the second session ("No-Show" fee).
Telehealth: Services that are provided through telebehavioral health technologies, use interactive electronic technologies between a clinician and client(s) who are not in the same physical location. By accepting the conditions outlined throughout this form you are acknowledging that: you must maintain visual and audio privacy during telehealth sessions including an appropriately private, quiet location without distractions from other people or devices. Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. Telehealth may provide access to treatment that would not otherwise be available to you. You will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. The exchange of written information may be indirect, via screen, email, or post. During your telebehavioral health consultation, details of my medical history and personal health information may be discussed within the group at your discretion through the use of interactive video, audio, or another telecommunications technology. Telehealth services may be discontinued by Connections due to changes in government regulations, insurance, or policy. Upon the beginning of each session, the clinician will request the client's location in case of an emergency. The laws and professional standards that apply to in-person behavioral services also apply to telehealth services.
I have read the above information and have been notified of my rights and grievance procedure available to me. I hereby give my informed consent to engage in the Alcohol BASICS Program and therapy services.
I do not agree and require more information
A copy of your responses will be emailed to the address you provided.
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