Online Counseling Request Form

Welcome to the Online Counseling Request form! Please read the Informed Consent and Privacy Protection and then complete the following information. The information helps us in addressing your question. Once we receive your request, we will contact you as soon as possible with information. This may take 48 hours during the regular business week, we will not respond on weekends or holidays. If you have any questions, please contact the Counseling Office at (805) 654-6448. Our regular hours at Monday - Thursday, 8:00 am to 7:00 pm, and Friday, 8:00 am - 3:00 pm.

*This form is for academic counseling only. To report a crisis or emergency; contact appropriate authorities.

Informed Consent Statement

To all Ventura College, VCCCD District students, and potential students:

Below are the terms and conditions for using the Online Counseling Services at Ventura College. Please read and click the appropriate button below to continue.

Information about you is confidential. It is important that you supply the most current information about yourself, including your educational history, plans and career goals, so that online counselors may provide you with the most accurate information to meet your needs.

• Wherever “Online Counseling” is mentioned, I understand this is referring to the online counseling services provided by Ventura College academic counselors. These services may include, but are not limited to, the use of an unsecured email for quick general questions.

• Per the Family Rights and Privacy Acts, I hereby understand that in order to receive pertinent information I must grant permission for Ventura College online counselors to release academic information about myself.

• When using the “Online Counseling” function, I understand that these interactions will be communicated through an unsecured email, and is to be used for general questions only. Therefore, I understand that I will not share my confidential student record information, via this option, nor will the counselor provide or discuss my student records via this option.

• I will protect my student ID# and password by not sharing this information with others.

• I authorize the online counselor to provide me with information appropriate for use on the online counseling website

• I authorize the online counselor to record email encounter for statistical purposes only.

• I am giving my permission, for only VC counselors, relevant VC personnel and VCCCD web server personnel (administrator) to, when necessary and for the sole purpose of improving the online meeting services, have access to recorded information from any email encounters between myself and a counselor.

Privacy Protection

I understand that when using Ventura College’s online counseling services, I must protect my personal information from others; therefore:

• I have provided an accurate and private email address. I understand that the Online Counseling program will automatically email confirmation messages and notifications to the address I provide.

• I understand that in the event I forget my email password or student ID# that I may request from the Online Counseling program an email with this information to the email address I have provided.

• I understand that every time I request information my email address should be accurate and private.

• I understand that I am NOT to share an email account with anyone. However, if I choose to share an email account with another person, I understand I may be allowing that person access to my personal and academic information.

• If I choose to share an email account, I release Ventura College Online Counseling Services from any liability resulting from such action.

 

I have read the above information in detail. I understand and agree to the Terms and Conditions established for Ventura College Online Counseling Services. *
Yes
No
First Name *
Last Name *
E-mail Address: *
Ventura College Student ID (if uncertain, type unknown)
Phone Number *
Are you currently enrolled at Ventura College? *
Yes
No
Are you currently enrolled in an online course at Ventura College? *
Yes
No
Have you attended any colleges or universities otherthan Ventura, Oxnard or Moorpark College? *
Yes
No
If you have attended other colleges or universities, besides Ventura, Oxnard or Moorpark College, are your transcripts on file with the Admissions and Records Office? *
Yes
No
Intended Major/Certificate of Achievement *
Current Educational Objective *
Certificate of Achievement
AA degree in General Studies
AA degree
AS degree
Transfer without AA/AS or certificate for BA/BS degree
Other
If other, please write in what your educational objective includes:
Your counseling question? *
Verification Code:
Enter Verification Code: *
* Required  
Last Updated 10/15/09
Ventura College does not discriminate on the basis of age, color, creed, religion, disability, marital status, veteran status, national origin, race, or sex.