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Student Care Coordination Intake Form


IF THIS IS AN EMERGENCY – DO NOT USE THIS FORM.

GO TO YOUR NEAREST EMERGENCY ROOM, OR CALL VUPD (615-421-1911) OR 911

If you have previously visited SCC, you do not need to complete this form. Please reach out to the care coordinator with whom you previously met or call our office at 615-343-9355 to schedule a follow up appointment.

 

How can Student Care Coordination help? 

  • Think “Google Maps” for support! SCC’s job is to help undergraduate, graduate, and professional students navigate and connect with campus and community resources that will best address challenges that may relate to academic, personal, emotional, medical, financial, or any other needs.
  • It is important to note that care coordination is not counseling or therapy. Rather, Student Care Coordinators have the opportunity to develop close helping relationships with students while coaching them toward appropriate resources, self-care, and self-advocacy.
  • SCC partners closely with the University Counseling Center (UCC) and conducts intake assessments to schedule appointments at the UCC for therapy and/or medication management.
  • During your first appointment, SCC will discuss your current needs, help develop a plan for success, explore and make connections to referrals that may be helpful, and schedule any follow up appointments, if needed.
  • For more information about how SCC can assist, visit https://www.vanderbilt.edu//carecoordination/

 

The information collected with this intake form is used to better understand what your goals are in working with the Student Care Coordinator and how we can best support you. The demographic information is asked for reporting purposes to ensure we are serving all Vanderbilt students appropriately.

Student Information

 
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Additional Information

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Questions

CONFIDENTIALITY & CONSENT Student Care Coordination (SCC) is committed to supporting undergraduate, graduate, and professional students in successfully navigating life events related to academic stress and/or medical, mental health, and/or other personal concerns that may interfere with their ability to achieve their academic and personal goals. Student Care Coordinators collaborate with students to develop a student success plan, facilitate connections to appropriate on- and off-campus resources, and provide accountability through supportive follow-up meetings. Your participation in creating this plan and following through with referrals and recommendations is a vital part of the process. Though staff are typically made up of mental health professionals, it is important to understand that your work with a Student Care Coordinator is NOT counseling or therapy. The services of SCC fall under the Family Educational Rights and Privacy Act (FERPA). This means the content of meetings with a Care Coordinator is private; however, information may be shared on a need-to-know basis with appropriate personnel within Vanderbilt University in order to provide you with the best care. There may be circumstances in which minimally necessary information is shared with SCC’s partners in the Student Care Network (University Counseling Center, Center for Student Wellbeing, and/or Student Health Center) for the purposes of care coordination. If it is necessary to share information with off-campus providers or others, you will be asked to sign a written release. If you prefer to speak with someone who can maintain confidentiality, please do not complete this form. Contact Student Care Coordination and they will arrange an appointment with a confidential resource. Student Care Coordinators take seriously their role to foster a safe campus for you and for others, which means there are certain limits to the privacy statement above that will result in a report to the appropriate University office(s), including when there is:
  • Evidence of clear and imminent danger of harm to self and/or others;
  • Reason to believe that a student is in danger of significant physical or psychological harm as a result of being unwilling or unable to follow treatment recommendations;
  • Information about abuse (past or present) or potential abuse occurring against a minor or vulnerable adult; or
  • Information about an instance of past or present sexual misconduct, including sexual assault, sexual harassment, stalking, dating violence, and domestic violence that may have occurred on or off campus.
    • If you wish to speak with someone confidentially about these issues, please contact the Project Safe Center at (615) 322-7233 or call SCC and ask to speak with a confidential resource. Should you disclose information about sexual misconduct to SCC, this information will be shared with the Title IX and Student Discrimination Office and you will receive an email offering resources and inviting you to meet. Please note it is your choice as to whether to respond to this email or not, and participation in an investigation is not required to receive support services.(Required)
    You must make at least one selection.
Who referred you to Student Care Coordination? (select ALL that apply)(Required)
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Select the area(s) of your life in which you may be having challenges and/or concerns at this time:(Required)
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Have you ever been hospitalized for emotional OR drug/alcohol treatment?
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Are you seeking assistance related to a traumatic event, either past or present? (By checking "yes", SCC will not automatically need to notify the Title IX and Student Discrimination Office, however any details added to this report as it relates to sexual misconduct WILL need to be reported. Please review the CONFIDENTIALITY & CONSENT above.) *Examples of trauma may include sexual assault, interpersonal or dating violence, unwanted sexual contact, natural disasters, accident, personal injury, sudden death of a loved one *
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How do you prefer to meet with your care coordinator for your intake appointment? (Please choose the same selection here and on the Student Portal. If you choose a different appointment type on the Student Portal, the appointment type you choose will replace your preference below.) In an effort to connect students with resources more quickly, SCC will be offering in-person Drop-In Care Coordination at various times and locations during the week. Please visit www.vanderbilt.edu/carecoordination to view the drop-in schedule. Please consider attending one of these drop-in times as an alternative to a scheduled appointment.(Required)
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