Employee Counseling Center

Employee Initial Intake Assessment

Mt. SAC Employee Counseling Center

Building 7, Rm 1107, 1st Floor

909 274-6211

For assistance completing the intake form, please contact the ECC at 909 274-6211.

If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.

For on-campus emergencies, contact Police and Campus Safety at 909 274-4555 for assistance.

employeecounselingcenter@mt.sac.edu

* denotes required field

Signature is required

Employee Assessment

Employee First Name:

Employee Last Name:

Employee ID (A #):

DOB (MM/DD/YYYY):

Mt. SAC Email:

Personal Email:

Address

Address 2 (Apt, Unit)

City/Town

ZIP Code

Phone Type:

Cell Phone #:

Gender:

Emergency Contact Name, Relation:

Classification Status:

Emergency Contact Phone #:

Relationship Status:

Race/Ethnicity:

Housing Insecure?

Do you require special accommodations? (i.e. wheelchair accessibility, deaf/hearing interpretation etc.)

How did you hear about the ECC services?

If yes, please explain:

Seeking mental health services related to:

Alcohol/Substance Abuse

Binging/Weight Problems

Excessive Worrying

Feeling Overwhelmed/Stressed

Grief/Loss

Relationship/Family

Sadness/Feeling Blue

Self-Esteem

Sexuality

Work Related

How long have you been concerned about these issues?

How disruptive are your concerns to the rest of your life?

Currently under care of a Mental Health Therapist?

Mental Health Therapist:

Phone #

History

Psychiatrist

Phone #

Past/Current Medication (s):

Background Information:

Family Background History (Relevant to family functioning and support, trauma issues, etc.)

Substance Abuse/Dependence (Past, present, severity of problem, etc.):

Medical History (Chronic illnesses, prior hospitalization(s), dates/locations):

Mental Health (Counseling history, treatment, medications, hospitalization (s), illnesses, current/hx of SI/HI/access to lethal means):

STATEMENT OF UNDERSTANDING

Consent for TeleMental Health Services
Informed Consent to Counseling Services
Privacy Notice HIPPA

I have read and agree to the Consent for Telemental Health Services

I have read and agree to the Informed Consent to Counseling Services

I have read and agree to the Privacy Notice HIPAA

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

The Mt. SAC Employee Counseling Center provides short-term mental health support to Mt. SAC employees. The information provided in this intake form is confidential and used solely to assist clinicians in preparing for your session. By pressing the “Submit” button, you consent to using your information for clinical purposes.

This confidential information is protected by federal and state laws and regulations, including, but not limited to, applicable Welfare and Institutions Codes, Civil Codes, and HIPAA Privacy Standards. Duplication or further disclosure of this information is prohibited without your prior written authorization, unless otherwise permitted by law.

In accordance with California law (Business and Professions Code §§ 4980.49, 4993, 4999.75), your health service records will be retained for a minimum of seven (7) years following the conclusion of therapy or, if you are a minor, for seven years after you reach the age of 18. You may request access to your records during this retention period. After the required retention period, all records will be securely destroyed in compliance with state and federal confidentiality standards.

Thank you for entrusting the Mt. SAC Employee Counseling Center with your care.

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