Forms & Waivers

Prior to your first physical and mental health appointment, a health chart must be completed for each. See the links below to fill and sign the forms online using Adobe sign.
After completing the forms, connect to our virtual lobby or send us an email to studenthealthcenter@cuesta.edu and let us know that you have completed the forms and would like to schedule an appointment with a nurse or therapist. Please, notify us if you need bilingual support (Spanish/English). You will be contacted by email/phone by one of our team-members to schedule your appointment. Please note: the phone number may appear as a restricted/blocked number. Be sure to provide the best dates and times to schedule your appointment.

After each form is completed and submitted, future appointments can be scheduled by visiting our virtual lobby.

The quickest way to schedule an appointment is by connecting to our virtual lobby or sending us an email to studenthealthcenter@cuesta.edu asking to schedule an appointment for Mental Health Therapy or Nursing Consultation (physical health). 
*Please, make sure you have previously completed the online forms using Adobe sign.
Remember, forms for Mental Health appointments are different to Nursing consultation forms.

1. Visit our virtual lobby available on our website. You’ll have the opportunity to interact
with one of our team staff during specific hours.
2.Use the option to ask a nurse, also available on our website.
3. Check our health resources: We have compiled this collection of campus, community and online resources to help students find safe and reliable information related to health and wellness. Click the links on the left sidebar to take you to specialized information. Some links will take you to sites outside the Cuesta College web server and Cuesta College has no control over the content or availability of these sites.
4. Explore our Educational Repository: Digital, educational, communicative material to promote health and well-being among the Cuesta Community, or Follow us on social media on Instagram/Facebook @cuestahealthcenter for educational information, tips, advice, events and updates.

If you would like to meet with one of our therapists, please complete all 5 sections (9 pages) of this form promptly and no later than 48 hours prior to your meeting time to avoid cancellation of your appointment.

To complete the Mental Health Form click here 

After completing the form, connect to our virtual lobby or send us an email to studenthealthcenter@cuesta.edu and let us know that you have completed the forms and would like to schedule an appointment with a therapist.

We may contact you by email/phone. Please note: the phone number may appear as a blocked number and be sure to provide the best dates and times to schedule your appointment.

If you would like to meet with one of our nurses, please complete all 4 sections (8 pages) of this form promptly and no later than 48 hours prior to your meeting time to avoid cancellation of your appointment. After the form is completed and submitted, future appointments can be scheduled by visiting our virtual lobby.

To complete the Nursing Consultation Form click here 

After completing the form, connect to our virtual lobby or send us an email to studenthealthcenter@cuesta.edu and let us know that you have completed the forms and would like to schedule an appointment with a nurse.

We may contact you by email/phone. Please note: the phone number may appear as a blocked number and be sure to provide the best dates and times to schedule your appointment.

Telehealth services Form // Consent to receive TeleHealth services with the Student Health Center (SHC) staff and providers.

Consent for Minors Waiver // If you are a student and are under the age of 18 this waiver must be filled out prior to any physical or mental health appointments at the Health Center. 

Authorization to Release or Disclose Patient Information // All appointments at the Health Center are confidential, however, if you would like to release information about your sessions and appointments to someone or an entity this waiver must be filled out.

Appeal form for mental health therapy // Not showing up for an appointment is considered a cancellation. Less than a 24-hour notice requires filling out an appeal form.  Please review our policy. 

NEAT Intake Forms // If you are scheduling an appointment with our Nutrition Education Action Team, please bring these forms filled out to the Health Center no later than 48 hours before your appointment.  

Student Accident & Injury Report // In the event of an accident, injury or illness on campus, a student report must be submitted to the Student Health Center within 48 to 72 hours. The report should be filled out by the faculty or staff member who was advising the student during the time of the accident or injury before being turned into the Health Center. Once that report is submitted the student can begin to fill out paperwork for supplemental Student Accident Insurance at the Health Center. 

Accident Reporting and Insurance // Cuesta College has limited supplemental Student Accident Insurance for injuries sustained during school-related accidents and activities. If you have other medical insurance coverage, all benefits under that policy must be fully utilized before the Student Accident Insurance policy applies. The Student Accident Insurance company will determine the eligibility of all submitted claims. It is the student’s responsibility to be evaluated, and fill out insurance paperwork at the Student Health Center within 72 hours.

Health Insurance information and more resources available here

Mental  Health  Therapy  appointments are in  high  demand;  because of  this,  a  24-hour  notice  is required to  cancel   an appointment.  This  allows  us  to  serve as many  students as  possible.  Not showing  up  for  an appointment  is considered  a  cancellation.  Less than  a  24-hour  notice  requires  filling  out  an  appeal form. 
Our  policy  is  as  follows:  

• The 1st  cancellation  that  is  less  than  24  hours  will  require  filling  out  an  appeal  form  in  order  to reschedule.  You  may reschedule  at  the  time  you  turn  in  the  appeal  form.
• The 2nd  cancellation  that  is  less  than  24  hours  will  require  turning  in  an  appeal  form  and waiting  for  the  therapy staff  to  review  and  sign  the  form.  They will  decide  if  you  may reschedule.  This  may take  up  to  2  days  for approval.
• The 3rd  cancellation  that  is  less  than  24  hours  will terminate  your  ability  to  receive  Health Center  Therapy Services  for  the  remainder of  the  semester.  You  will  receive referrals  to  lowcost  services  in  the  community in  the  event  that  you  are  ineligible  for  services  at  Cuesta College.