Care Clinic Referral for MISD Employees

Cualquier información que se haya obtenido en este formulario se usará con el propósito de programar una sesión de consejería en la clínica CARE

Required

Disclaimer: Any information obtained for this form will be for the purpose of scheduling a counseling session with the CARE clinic and will not be shared with your employer at any time.

The services you receive at CARE clinic are confidential and not associated with your employment with Mesquite Independent School District. Please complete this form to the best of your ability to give us an understanding of your current needs.

Demographic Information

Employee Name*required

Job Title*required

Campus: *required

Feeder pattern if applicable:

Personal Email*required

Cell Phone Number*required

Gender:*required

DOB*required

Race*required

Primary Language*required

Marital Status*required

Children*required

Emergency Contact*required

Relationship to Emergency Contact*required

Emergency Contact Phone Number*required

Counseling Needs

What concerns do you hope to address in counseling? *required

Have you had counseling before? *required

Start date: *required

Must contain a date in M/D/YYYY format

End date: *required

Must contain a date in M/D/YYYY format

Reason: *required

Please list any current medications: *required

Have you experienced any thoughts of harming yourself?*required

Please give more information:

If you are suicidal or this is a true emergency, please dial 911 for immediate assistance.

On a scale of 1-5, please rate how you currently feel.

Current level of anxiety*required1=low 5=high

1=low 5=high

Current level of depression*required1=low 5=high

1=low 5=high

Current level of stress*required1=low 5=high

1=low 5=high

Please briefly describe the source of your distress:*required

Appointment Preferences

Please complete the preferred appointment information below. We currently have a waiting list but will try our best to match you with someone as soon as possible. Completing the below information allows us to match a counselor with your availability.

Would you rather have in-person or telehealth appointments?*required

Appointment Preference: *required

Preferred day of the week:

Monday

Tuesday

Wednesday

Thursday

Best time for apppointment:

Conference/Lunch time:

Is there anything else that you would like to share with us?

Email Address

Only include if you would like a copy of your referral.