WelcometoOxfordCollegeCounselingandCareerServices.

Wearegladyouhavedecidedtoutilize
ourservices.Ifyouareinterestedinmeetingwithacounselor,thereisasmallamountofpaperwork
thatmustbefilledout.Pleasebeginbyindicatingwhattypeofserviceyouhavecomefor:

____Consultation (Wishtodiscussareferral,anotherstudent,classproject,aprogram,etc.
Nopaperworkisrequiredforthisserviceseethesecretarytoarrangeanappointment.)

____ProblemSolving Session (Generallyaonetimeonlyvisittoaddressaveryspecific

problemordecisionmakingdilemma,forwhichyoufeelyouneedsomeconfidential,
professionaladvice.

____IndividualCounseling (Counselingisacollaborativeprocesswhichinvolvesthe
developmentofaunique,confidential,helpingrelationshipwithacounselor.Individual
counselingusuallyinvolvesmeetingonaweeklybasis(orasneeded)foralimited
periodoftime.)

____CareerCounseling (Assistanceindeterminingamajororcareerdevelopment)

____CouplesCounseling (Counselingwithtwoindividualswhoaretryingtoworkoutan
interpersonalrelationshipproblems)

Formstocomplete:

OnthefollowingpageyouwillfindtheInformationandConditionsofServiceform.Pleaseread
thiscarefullyandsign(keeptheyellowcopyforyourrecord).Ifyouhaveanyconcernsaboutsigning
thisform,youmaywaitanddiscussthemwithacounselorhowever,wecannotprovidecounseling
serviceswithoutyourconsent.

Note: Ifyouareunder18yearsofage,youmustreadandcompleteanadditionalform.Pleaseinform
thesecretaryoroneofthecounselors.

Finally,completethePersonalDataQuestionnaire.Thisformasksfordemographicandpersonal
informationneededtoassistthecounselingprocess.Thisformiskeptstrictlyconfidential andwillnot
bereleasedtoanyonewithoutyoursignedconsent.Afteryouhavecompletedthisform,youwillneed
tospeakwiththesecretarytomakeanappointmentwithoneofthecounselors.

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 OXFORD COLLEGE COUNSELING AND CAREER SERVICES
INFORMATION AND CONDITIONS OF SERVICE
Counseling and Career Services (CCS) provides a variety of services to students, including individual, couples and group
psychotherapy, problem solving sessions, psychiatric evaluations and medication management appointments. CCS also offers career
counseling, career assessment, and outreach programs. Services are provided by licensed psychologists, licensed social workers,
psychiatrists, or psychology students pursuing their doctorates and under weekly supervision by our staff psychologists. If you have
any concerns about your experience with CCS, do not hesitate to contact the Director, Counseling and Career Services or the Dean for
Campus Life.

Please read the following conditions for service at CCS.

1. The information shared in a counseling session is confidential and will not be disclosed outside CCS without your written
permission except: when disclosures are legally required including but not limited to situations where child abuse is suspected;
when your counselor or psychiatrist has reasonable cause to believe that you present a danger to self or others; or, in response to a
valid court order. The information gathered during a session may be shared among staff of Oxford College Counseling and
Career Services, Oxford College Student Health Service, and among Emory Health Service psychiatrists for the purposes of
coordination of care, consultation, and/or supervision. Your counselor and/or psychiatrist will address conditions for the sharing
of information among your treatment providers.

2. Clinical records are stored in locked filing cabinets. CCS does not provide student workers access to clinical records. Student
workers sign a confidentiality agreement and any breach of this agreement will result in their immediate dismissal. On occasion
we may request your consent to audiotape your counseling sessions for supervisory purposes. Taping will occur only with your
written permission which we will request via a separate form. Your counselor will discuss with you conditions for audiotaped
recordings.

3. When you request our services, you will be scheduled for an intake interview so that a counselor can most appropriately evaluate
your needs. The counselor will meet with you for approximately 45 minutes to determine what resources either within or outside
CCS will most effectively address your concerns. Please be advised that in some cases your intake counselor will not be the one
to provide services beyond the intake interview.

4. Most services at CCS are free. There is a minimal fee for career testing. Your counselor will provide appropriate referrals if the
service you require is unavailable. Services offered outside CCS generally involve a fee. In most cases, health insurance will
cover some of the cost.

5. Please contact CCS at least 24 hours before your scheduled appointment if you need to cancel or reschedule. Our services are in
high demand. If you do not cancel your personal counseling or psychiatry appointment at least 24 hours in advance, you
will be charged a $10.00 fee for a missed appointment. By being courteous and canceling your appointment 24 hours in
advance, you allow other students the opportunity to meet with your counselor during the time you surrendered. (The fee for a
missed appointment may be waived at the discretion of the CCS counselor.)

6. If your personal counseling sessions are ongoing and you miss two consecutive appointments without notifying our office, we
will assume you are no longer interested in receiving our services and your ongoing appointment time will be released.

Please discuss any questions or concerns with your intake counselor before signing.

I have read and understand the conditions listed above and consent to them.

_________________________________________ _________________________________________
(Print Name) (Signature* & Date)

*Signature of parent or guardian may be required for students under 18 years of age

OXFORD COLLEGE COUNSELING AND CAREER SERVICES

(770) 784-8394
 OXFORDCOLLEGECOUNSELINGANDCAREERSERVICES

PERSONALDATAQUESTIONNAIRE
FORCAREERSERVICES
(Confidential)

TodaysDate_______________________

Name________________________________________Age _______DateofBirth_____________________
Gender:Male_______Female_______Intersex_______Transgender_______
Class:Freshman_______Sophomore_______ MaritalStatus:________

EthnicIdentification: Citizenship:_______________________________________
qAfricanAmerican/Black qAlaskan/NativeAmerican
qAsian/PacificIslander qEuropeanAmerican/White
qHispanic/Latino(a) qMultiracial
qIndian/MiddleEastern qOther________________________________________________________

OxfordMailingAddress: ___________________________________________________________________
CampusTelephoneNumber:______________ EMailAddress:___________________________________
ResidenceHallRoom#:______________________________CellPhone:____________________________

CheckwhichmodesofcommunicationfromCounselingandCareerServicesyoufeelcomfortable with:
Contact: _____Phone_____VoiceMailMessage_____EMail_____Mail
AppointmentReminders: _____Phone_____VoiceMailMessage_____EMail_____Mail

PermanentMailingAddress:
Street____________________________________________________________________________________
City____________________________________________State____________________Zip_______________
TelephoneNumber: _______________________________________________________________________

Nameofpersontocontactincaseofamedicalorpsychologicalemergency:_________________________
_________________________________________________ Relationshiptoyou_______________________
Addressofthiscontact: ____________________________________________________________________
TelephoneNumber: HomePhone_______________________WorkPhone__________________________

WhoreferredyoutoCounselingandCareerServices? ___________________________________________

Maywecontactthispersontolethim/herknowyoucametoCounselingandCareerServices? Yes No
Suchcontactwouldrequireyourwrittenconsentpleasesignifyoucircledyes.Duetoconfidentiality
requirements,noinformationotherthanthatyoucameforanappointmentwouldberevealed.

__________________________________________
Signature

Pleasecirclethosetimesforwhichyouwouldberegularlyfreeandwouldprefertocomeinfor
appointments.Doyoubelieveyoursituationrequiresimmediate(emergency)attention? YN

Monday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00

Tuesday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00
Wednesday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00
Thursday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00
Friday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00
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Pleasebrieflydescribethenatureofthecareerrelatedissuesforwhichyouareseeking
assistancefrom CounselingandCareerServices:________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Pleasedescribehowyouracademiclifeisgoing. (Bespecific:e.g.,grades,studyhabits,class
attendance,interactionswithfaculty,etc.) ________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Pleaselistyour nonacademicinvolvementsorresponsibilities.(e.g.,work,clubs,SGA,etc.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Isthereanythingelseyoubelievewouldbeimportantforustoknowinordertoassistyou?(use
thebackofthissheetifnecessary)______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

WheredidyoulearnaboutCounselingandCareerServices?
____CounselingandCareerServicesPublicity (specify)_____________________________________
____Faculty/Instructor____ StudentHealth____RLC____RA____PAL____Dean
____Friend/student____StudentDevelopment____Parent____Other(specify)_____________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Rev 8/08

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