Counseling Center Forms

The Counseling Center has provided several frequently used forms for your convenience. Please see below for an explanation of each form’s use and a link to download the form.

Student Health & Well-Being Mental Health Services Consent Form

The Johns Hopkins University Student Health and Well-Being Mental Health Services organization (a.k.a. SHWB MHS) provides mental health treatment and well-being support to Johns Hopkins University students and learners at locations in our Baltimore and Washington D.C. area campuses. The SHWB MHS includes several clinic locations and entities: the Johns Hopkins Counseling Center (CC), the Johns Hopkins Student Assistance Program (JHSAP), the Johns Hopkins Behavioral Health Crisis Support Team (BHCST), University Health Services Mental Health (UHS-MH). The SHWC MHS consent form can be found PDF Document: here.

Privacy Practices Notice

Notice of Privacy Practices for the Johns Hopkins University Student Health and Well-being Division. This notice described how medical information about you may be used and disclosed and how you can get access to this information. The Privacy Practices Notice can be found online PDF Document: here.

Release of Information

The Counseling Center does not disclose any information about a client without written permission (please see our Confidentiality Policy). If you would like someone to be able to communicate with the Counseling Center about your treatment, you must fill out a PDF Document: Release of Information Form. You may come in to the Counseling Center and fill one out or you may print it from this website, fill it out at home and bring it to the Counseling Center, or fax the completed form to us at 410-516-4286.

Release of Information (specific to WellFleet)

As stated above, the Counseling Center does not disclose any information about a client without written permission. Students who are enrolled in the JHU student health benefit plan, which is administered by Wellfleet Group, LLC and contracted with Cigna, may wish to grant the Counseling Center permission to submit a Referral Authorization form on your behalf. The Referral Authorization form notifies the insurance company that the JHU Counseling Center has referred you to a community mental health provider and will reduce your $150.00 insurance deductible to $75.00. Once submitted, a copy of the Referral Authorization form will be sent to you via email for your record and in case your new mental health provider wants documentation verifying your reduced deductible eligibility.

If you would like the Counseling Center staff to communicate with Wellfleet and reduce your deductible, you must fill out this PDF Document: Release of Information for WellFleet Insurance. You may come in to the Counseling Center and fill one out or you may print it from this website, fill it out at home and email it to rcmt@jhu.edu.

Medical Leave of Absence

For more information on Medical Leave of Absence and reinstatement, please visit the Office of the Dean of Student Life’s Medical Leave of Absence page.