Forms & Waivers
Prior to your first physical and mental health appointment a chart for each must be filled out. You can come to the Health Center office to fill it out, or click the links below to print and familiarize yourself with some of the paperwork. The first health appointment must be made in person at the Health Center, from there after you are free to call to schedule further appointments.
Mental Health forms:
If you would like to meet with one of our therapists, this forms must be filled out prior to scheduling your first appointment. Once this form is filled out and with the Health Center, you are free to call to schedule further appointments over the phone.
Parameters of Mental Health Therapy // This form outlines the parameters for our mental health therapy sessions, and includes an outline of the no-show policy in place
Physical Health form:
Consent for treatment PH // If you would like to meet with one of our nurses & practitioners this form needs to be filled out and submitted to the Health Center.
"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.
"Release of Information Authorization" Waiver // 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.
"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. Print this permission form too.
"HIPPA Notice of Privacy Practices" //This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
*All of these forms are available to fill out in the Health Center
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.