Forms

Health and History Form

A completed Health and History form along with a proof of immunization record are required upon entrance to the University. Along with the immunization record should be proof of the mandatory TB screening. These forms are required in order to use the Wellness Center services, and students who do not provide these documents will be unable to pre-register for classes.

Release of Information

If you wish us to share healthcare or counseling information you must complete and submit to the Wellness Center a Release of Information. All information about a student is considered confidential and is to be released only to authorized personnel. We are not permitted by law to disclose any counseling information to a parent, guardian, or anyone else without the consent of the student unless the student is mentally incapacitated or threatens to harm him/herself or someone else. This means that any information disclosed during your contact with Kettering University Wellness center will be kept strictly confidential as required by the FERPA and HIPAA Act, and by applicable ethical standards.

Counseling Intake Form

The following intake forms are to be filled out by all new counseling clients before the initial intake appointment.  If you are unable to complete your intake forms ahead of time or forget to bring them, you will need to arrive 15-20 minutes early.  

HIPAA Policy

In compliance with the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191 as amended) (“HIPAA”), Kettering University has adopted the following Health Insurance Portability and Accountability Act Policy to ensure reasonable protection of Protected Health Information (“PHI”), as defined by the Code of Federal Regulations 45 C.F.R. 160.103. It is the intent of this Policy to act as a supplement to, not a replacement for, other University Policies.