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CHHAMH-U Student Intake Form
This list is now closed. Anyone who signed up after July 22 will be added to the wait list.
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* Indicates required question
First and Last Name
*
Your answer
Race or nationality
*
Your answer
Email
*
Your answer
Home address
*
Your answer
Zip Code
*
Your answer
Phone number
*
Your answer
Age (If under 18, First and Last name of parent or legal guardian with phone number)
*
Your answer
Are you currently employed? If so, please describe what kind:
Your answer
Are you insured?
*
Yes
No
Unsure
If you are insured, what kind?
Your answer
Please describe what you are going through and what issues bring you to CHH&MH University.
*
Your answer
Are you currently experiencing any hardships? - (check all that apply)
*
Housing
Food
Grief
Required
Have you ever had a mental health diagnosis from a mental health or medical professional?
Yes
No
Prefer not to answer
Clear selection
If yes, what was your diagnosis? You don't have to share if you're not comfortable doing so.
Your answer
What type of therapist are you looking for?
*
Your answer
Which therapist would you like to have sessions with?
(We are currently updating this list.)
To choose your therapist, click
here
*
Your answer
Do you have a history of suicidal thoughts and/or behavior?
*
Yes
No
Prefer not to answer
What is your availability for therapy?
*
Your answer
How far are you able / willing to travel to receive therapy?
*
Your answer
Can you fully commit to the full 5-month program?
*
Yes
No
Should your personal situation change, will you update us accordingly?
*
Yes
No
Anything else you'd like to share with us?
Your answer
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