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Intake Form

 

e-Counseling is available to students enrolled in online classes and who live too far from the campus to conveniently access services. Before completing the Intake Form below, you must read the e-Counseling FAQs (Frequently Answered Questions) and the e-Counseling Confidentiality Agreement.

 

e-Counseling Services include basic educational planning. Because of the Family Educational Rights and Privacy Act (FERPA), Berkeley City College e-Counselors will only provide general information. Due to the high volume of student emails, responses are not immediate and it may take up to three working days to receive a response.

 

Intake Form Instructions

Please read the e-Counseling FAQs and the e-Counseling Confidentiality Agreement first. Then fill out the e-Counseling Intake Form below. If you cannot read the form below, please contact the Counseling Department at counselingbcc@peralta.edu or (510) 981-5036.

 

Some items in the form are denoted as: (required) . Please enter all required information, otherwise the form will not submit and error messages will be displayed. A copy of your form information will be emailed to you, so please enter a valid email address when completing the form. If you do not receive the email message, please check your spam folder in your email account.

 

e-Counseling Intake Form:

1. e-Counseling FAQs and Confidentiality Agreement

I have read the e-Counseling FAQs (required).
Enter the FAQ Keycode  

 

I have read the e-Counseling Confidentiality Agreement (required).
Enter the FAQ Keycode 

 

 

2. What Online Courses Are You Enrolled In?

List your current online courses below. If you are disabled and not enrolled in online courses, please indicate this in the space provided (required):

 

 

3. Have You Submitted A Question To e-Counseling Before?

(required)
 No Yes

 

 

4. Student Data - you must have a Peralta Student ID #

First Name: (required)

Last Name: (required)

Student ID Number: (required)

Phone Number: (required)

Email Address: (required) Please double-check your email address.

 

 

5. Have You Attended Other Universities or Colleges Outside of the
Peralta District?

 No Yes

If yes, please list where you've attended:

 

 

6. What is your intended major?

 

Major:

 

 

 

7. Educational Objectives (check all that apply)

 Certificate AA/AS Degree BA/BS Degree Undecided Other

If you checked "Other" educational objectives, please describe below:

 

 

8. Reasons For e-Counseling (check all that apply)

 Academic Career Matriculation Hold Probation/Dismissal SEP Initial SEP Update Transfer/Concurrent Enrollment/TAG Prerequisite Clearance - Documentation Required (upload file below)

Unofficial transcript accepted ( 1MB max; formats: .doc, .docx, .pdf).
Please browse to your file here (it will upload when you submit):

 

 


9. Services You Are Currently Receiving (check all that apply)

 Calworks PSSD (Program and Services for students with disabilities) EOPS/CARE (Extended Opportunity Programs and Services/Cooperative Agencies Resources for Education) TRiO

 

 

10. Enter Your e-Counseling Question Below (required)

 

 

 

 

11. Student Certification and Submission (required)

STUDENT CERTIFICATION: I have read the instructions and information accompanying this e-Counseling Intake Form for Berkeley City College. The information I have completed is true to the best of my knowledge, and I understand that it is illegal to report false or misleading information. By submitting this form, I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (Please check the box for Student Certification to continue. Then click the "Submit" button below to send your question and any attachment. You will receive a copy of the information in this form to your email address above.)

 

 

  • Counseling

    Monday 20 May 2013
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