Forms

All students must complete a registration packet prior to the first appointment. All forms, linked below, may be printed out and completed in advance of your appointment. (Please remember to bring these forms with you to the appointment.) If you prefer to complete these forms on the day of your appointment, please do your best to arrive 10 to 15 minutes early. Registration packets are available in the SPCC waiting area. Students should also bring their Jefferson student I.D. and insurance card for verification.

• Authorization to Release Medical Information: Consent form that student completes to authorize the SPCC counselor or psychiatrist to release medical information to a designated third party.
  
  SPCC Registration Packet: The SPCC Registration Packet includes all the forms listed below.  Click on this PDF to print out all forms.
• Health History Form:   Provides the SPCC helpful information regarding your medical history, physical health and well-being.
• Acknowledgement of Receipt of Notice of Privacy and Authorization to Release Health Information:  Form to be signed by student upon receipt of the Notice of Privacy Practices of TJU, TJUH and JUP (see below).
• JUP Patient Registration Form: Provides the SPCC important information including identifying information, mailing address, insurance information, and designated emergency contacts.
• 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.  Please review it carefully.
• Scope of Services Form:   Information outlining the scope of services provided by the SPCC and EHWP as well as information about routine policies and procedures.