• Request for Services / Referral Form

    Community-Based Counseling (Wellness Program)

  • JFK School of Psychology and Social Sciences at National University has partnered with your school/agency to provide therapeutic, strength-based counseling support. In order to receive services, please complete this Request/Referral Form.  Counseling is confidential, as is this form.

    If you are a student currently enrolled at one of our partnering schools/colleges, you are eligible to request services through our Community-Based Counseling Profgram. Inforrmation discussed in treatment will not become part of your student record. Counseling through this program is typically brief, aimed at helping clients achieve reachable goals within an 8-12 week/session timeframe.

    _________________________________________________________

    Please note this program is NOT able to provide crisis counseling.  It will take time to process your request and your referral may be placed on a waitlist. 

    If you (or the individual being referred) are in need of immediate support, in crisis, and/or currently experiencing life threatening danger, please do NOT complete this form. Instead, please:

    • Call the 988 Suicide & Crisis Lifeline (formerly National Suicide Prevention Lifeline 1-800-273-8255),
    • Text the Crisis Textline - Text the word HOME to the number 741741,
    • Call SAMHSA's National Helpline, 1-800-662-HELP (4357) (in English and Spanish)
    • Call 911, or
    • Go to the nearest Emergency Room

    If you are a college student needing immediate assistance and are currently on campus, you can speak with an academic counselor, instructor, or administrative staff who can also assist you in finding support.

    _________________________________________________________

    If you (or the person referred) are not in need of crisis support, please click "Next" to continue.  You will be asked a series of questions to help us identify a counselor who would be a good fit for you (the potential client). 

  • Information of Referring Person

    For self- referral, the Potential Client is also the Referring Person


  • If you selected "No" to the above question, "...has the person being referred been notified about this referral?", please do not complete this form until you have spoken with the individual you are referring for service.  We will only take referrals for potential clients who know they are being referred and are willing to participate. 

  • * Denotes required field 

  • Information of the person being referred

  •  - -
    Pick a Date
  •  -

  • Please note the following:

    • Blocked calls
      • Make sure the number listed above is able to receive blocked calls as our counselor may call from a blocked number
    • Voicemail: 
      • Make sure the mailbox on your phone is set up and is NOT full so our counselor can leave a voicemail if permitted

  • Please note the following:

    • Blocked calls
      • Make sure the number listed above is able to receive blocked calls as our counselor may call from a blocked number
    • Voicemail: 
      • Make sure the mailbox on your phone is set up and is NOT full so our counselor can leave a voicemail if permitted

  • We permit the use of text messaging for the sole purpose of scheduling appointments with adults. Text messages are not to be used in the case of an emergency or crisis. Please do not include any sensitive, clinical information in your text message. This should be discussed in person, over the phone, or via video-conferencing only. Our counselors will do their best to respond to text messages within 48 hours.

    Communicating via text message has some risks and may not be secure. Threats to confidentiality include, but are not limited to the following: 

    • the transmission may be intercepted
    • the transmission may be sent to the wrong recipient
    • the text message may be accessed by an unauthorized person

    To preserve your confidentiality, we will do the following:

    • Password protect the device that we use to communicate with you
    • Use the Google Voice app so that your messages are stored separately from any personal messages
    • Delete your text messages within a reasonable timeframe after completing the interaction.
    • We will not store your name anywhere on our devices. 

  • If our initial outreach to you is by text message, it will state the following:

    Hello, my name is (__________) and I am from the JFK Community-Based    Counseling Program. I received your request for information, and I would like to schedule a time for us to talk. Please call me at this (xxx)xxx-xxxx(phone number) or respond to this text.

  • * Denotes required field

  • Questions Regarding the Referral

    Please provide some information regarding the reasons for this referral

  • +Please note that this service is NOT specialized in the treatment of addiction.  If you identify "substance use/abuse" as the primary concern and need specialized treatment for addiction, please consult a physician for appropriate referrals. 

  • ++Past crisis or trauma refers to prior experiences that the PC may still be struggling with but do NOT pose imminent risk of harm or safety to them or others. If you choose this item, please provide a brief narrative in the space below for the past crisis or trauma indicated.

    Please be reminded that this service does NOT offer crisis counseling. If the individual being referred is in need of immediate support for a major crisis and/or a life threatening danger, do NOT proceed with this referral. Instead, seek immediate assistance from the emergency resources listed at the beginning of the form.

  • +++Choose this item ONLY when current/ongoing crisis or trauma does NOT pose imminent risk of harm or safety to the person being referred or others. If you choose this item, please provide a brief narrative in the space below for the current/ongoing crisis or trauma indicated 

    Please be reminded that this service does NOT offer crisis counseling.  If the individual being referred is in need of immediate support for a major crisis and/or a life threatening danger, do NOT proceed with this referral.  Instead, seek immediate assistance from the emergency resources listed at the beginning of the form.

  • * Denotes required field 

  • Preference for Service and Availability: 

    Please note that in this academic year, we are offering in-person services at the colleges Mondays through Thursdays. Please choose "In-Person" below if you are requesting services at a college.

    For FJC clients, we are offering

    • in-person services at the Concord office on Wednedsays
    • and limited telehealth services through the Antioch, Richmond and Solano offices this year.

    Please indicate your preference for services below. We will try our best to offer services in accordance with your preference, but we cannot guarantee your preferred services will be available. Regardless of telehealth or in-person service, please also indicate your availability below.

  •  

  • Once you click "Submit," this referral will be sent to the National University, JFK School of Psychology and Social Sciences Community-Based Counseling Program (CBCP) Referral Team, to be reviewed and processed in a confidential manner.  A counselor from CBCP will reach out to you or the person you are referring as soon as an availability opens up to render services.  Please be advised that wait times could be up to 3-4 weeks.  If you or the person you are referring is in need of more immediate assistance, emergency resources are listed at the top of this form.

     

    rev. 11/15/24

  • Should be Empty: