Mental Health Referral Form

    Northwest State Community College (NSCC) offers free, short-term mental health counseling to currently enrolled students through an on-campus Clinical Services Provider. Services are designed to support well-being, build coping skills, and reduce risk in a confidential, judgment-free setting.

    Access to Services

    • -The Clinical Services Provider is the primary contact for mental health services.
    • -Call response hours: Monday–Friday, 9:00 AM–6:00 PM (weekend messages returned Monday).
    • -After initial contact, service options may include:
      • -Video consultation
      • -On-campus session
      • -Referral to community providers, including The Center for Child and Family Advocacy, Inc.
    • On-Campus Sessions
      • -Available Thursdays, 9:00AM- 1:00PM at the NSCC Wellness Center.
      • -Students may receive up to three (3) sessions, with additional sessions at the provider’s discretion.
    • Walk-In Requests
      • -Students may visit the Wellness Center during clinical hours or call 419-591-6487.
     

    Consent & Responsibility

    • -Mental health services must be requested by the student.
    • -By completing this form, you acknowledge that participation and follow-through are your responsibility.
    • -Communication will be limited to scheduling and care coordination. Information will not be shared with others without written consent, except as required by law.

    If you are experiencing a mental health crisis and need to speak to someone immediately, please contact one of these resources immediately as we do not have a crisis center.
    1. National Suicide Prevention Lifeline 988
    2. 911

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    **While this referral process is designed to maintain confidentiality to the greatest extent possible,
    there are technical limitations within Slate that prevent complete restriction of access. A limited number
    of Individuals assigned the “Administrator” role in Slate inherently have broader system access than
    standard users. As a result, it is not possible to fully prevent administrators from viewing form
    submissions, even when access restrictions are applied.