Forms - Cabrillo College

Watsonville Center

Faculty + Staff

Apply / Register

Students who have completed the following forms please email them to: healthservices@cabrillo.edu

COVID-19

COVID-19 Screening Questionnaire

COVID-19 Vaccine Minor Consent Form

COVID-19 Vaccine Accommodation Form

Authorization for COVID-19 Medical Information Release

New Client Mental Health Visit:

Acknowledgment of Privacy Practices and Consent for Treatment

Mental Health Intake Form

Annual Questionnaire

ACE Questionnaire

Alcohol screening questionnaire (AUDIT)

Drug Screening Questionnaire (DAST)

Mood Questionnaire (PHQ-9)

Establish Client Mental Health Visit:

Acknowledgment of Privacy Practices and Consent for Treatment

Annual Questionnaire

ACE Questionnaire

New Patient Medical Visit:

Acknowledgment of Privacy Practices and Consent for Treatment

Personal Health History Form

Annual Questionnaire

ACE Questionnaire

Alcohol screening questionnaire (AUDIT)

Drug Screening Questionnaire (DAST)

Mood Questionnaire (PHQ-9)

Establish Patient Medical Visit (seen 2016-2020):

Acknowledgment of Privacy Practices and Consent for Treatment

Annual Questionnaire

ACE Questionnaire

Other Medical Forms

Family Pact - Client Eligibility Certification (CEC)

Authorization for Release of Medical Information

Minor Consent Form

Release of Records

Physical exam for Allied Health Program

Other Forms

Presentation Request Form

Incident/Injury Form

Formularios en Español

Admisión de Servicios de Consejería y Salud para Estudiantes de Cabrillo College

Consentimiento para la vacuna de COVID-19 Para los menores de 18 años

Cuestionario bianual

Cuestionario de detección de alcohol (AUDIT)

Cuestionario de detección de alcohol (AUDIT - formulario rellenable)

Cuestionario de detección de drogas (DAST – Spanish)

Cuestionario De Experiencias Infantiles Adversas Para Adultos (ACE)

Reconocimiento de prácticas de privacidad y consentimiento para el tratamiento