This enrollment form should be completed by individuals who are 18 or older.
If you are between the ages of 12 to 17 and would like to self-consent forbehavioral health services, please contact:
support@healthycampus.com(855) 286-2577
If you do not have insurance, please DO NOT submit this form until you call the HEALTHY CAMPUS UNINSURED PROGRAM AT 909-287-1150. A representative will help you understand your options and explain how to complete the following section.
By signing below...