PACIFIC UNIVERSITY STUDENT COUNSELING CENTER
CONFIDENTIAL CLIENT DATA SHEET
Please provide the following information so that we can better serve you. As with all you share with the
Student Counseling Center (SCC), this information is treated with professional confidentiality.
Please contact us if this information changes.
Date:
Your Name:
last
first
middle initial
Name you would like us to call you (if different than above):
Date of Birth:
-
-
Age:
Student ID Number:
Local Address:
street
city
state
zip
Phone Number: (_____) ______-________ May we leave a message? Yes  No  /May we mention “SCC”? Yes  No 
Email: ______________________________________________ May we contact you via email? Yes  No 
In case of emergency, contact:
last
Relationship:
first
Phone (
)
-
Please circle your preferred gender pronoun:
She / He / They / Ze / Other ________
Ethnic Identity/Background: (check all that apply)
 Multi-ethnic/racial
 Asian American
 Pacific Islander
 Chicano/Latino/Hispanic
 African American
 Euro American/Caucasian
 American Indian/Alaskan Native
 Other
 International
 Decline to Respond
Relationship Status:
 Single/Non-Partnered
 Significant Relationship
 Married/Life Partner
 Separated
 Divorced
 Other
 Decline to Respond
Are You Employed?
 Yes
Where:
 No
Number of Hours Employed Per Week:
 1-5
 6-10
 11-15
 16-20
 more than 20
Number of Dependents:
 0
 1-2
 3 or more
 Relationship to Dependents: _____________
Who Referred You to SCC: (check all that apply)
 Family/Parents
 Advisor/Professor
 Partner/Spouse
 Friend
 Presentation
 Health Services
 Self
 Dean of Students Office
 Resident Assistant/Hall Director
 Other
Please WRITE IN Major or Prof/Grad Program:
 Major (Undergraduate):___________________
 Program (Prof/Grad): ____________________
Year in School:
 1st year
 2nd year
 3rd year
 4th year or higher
 Non-Pacific student/partner(couples only)
Who raised you (check all that apply)?
 Biological parent(s)
 Adoptive parent(s)
 Stepfamily
 Other ________________________________
Are they/were they:
 Married/Committed Partners
 Never Married
 Living Together
 Separated (Date:
)
 Divorced (Date:
)
 Mother Deceased (Date: _______)
 Father Deceased (Date: _______)
Number of Brothers/Sisters:
 0
 1-2
 3 or more
My family has a history of: (check all that apply)
 Counseling
 Psychiatric Hospitalization
 Alcoholism
 Abuse
 Depression
 Eating Disorders
 Poor Communication
 Other
 None of these
Where did you grow up?
Where do you consider home?
Are you currently (or within the past year) under the care of a medical doctor? Yes 
If yes, for what condition:
Do you have any other significant medical conditions? Yes 
If yes, please describe:
No 
No 
Are you currently taking any medications or herbs/supplements? Yes 
Name of medication/herb(s)/supplement(s), Dosage, Frequency:
No 
Who prescribed it for you?
Do you have a disability? Yes  No 
Please describe:
Have you had previous counseling or psychotherapy? Yes 
Where?
With Whom?
No 
Are you presently receiving counseling or psychotherapy from some person or agency other than this
service? Yes 
No 
Where?
With Whom?
Please indicate below the reason(s) you are requesting assistance and what you hope to accomplish:
Please indicate the degree to which each of these has been a
problem/concern in the past month:
no
little moderate significant
concern concern concern concern



 sleeping (too much/too little)



 mood shifts



 appetite







 concentration and memory



 trauma/crisis



 low energy/fatigue



 headaches



 sexuality






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 thoughts of ending my life



 intentions of ending my life



 anxiety



 panic



 change in activity level



 concerns regarding eating



 sadness/depression



 getting extremely angry



 trusting other people



 acting in a violent manner



 feeling like harming someone


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 absent from classes too often


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 thinking of dropping out of school




indecision about major/career choice


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
change in support system




go blank when I take tests


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
not sure Pacific University is for me


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identity issues


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too easily influenced by others

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financial problems


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don’t like my body

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religious/spiritual beliefs


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HIV or other STI concerns

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wasting time on the computer

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substance use

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unwanted thoughts or ideas

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satisfaction with sex I am or am not having




acting “not like myself”
worthlessness/guilt
weight loss/gain
I use alcohol or other drugs:
 once a week or less
 more than once a week
 do not use
I have suffered a recent loss:
 death
 relationship ending
 other (specify):
The following has resulted from my alcohol/
drug use. Check all that apply:
 traffic violation
 ruined relationship
 black outs
 fight with friend
 academic problems
 difficulties with memory
 other (specify)
I have had an unwanted sexual experience:
Check all that apply:
1. On the Pacific campus or in Forest Grove

this year

in the past
It was with:
 friend
 date/acquaintance
 someone I don’t know
 family member
I have experienced oppression regarding:
Check all that apply:
 ethnic identity (Jewish, Polish, etc)
 racial identity
 sexual orientation
 sex
 gender
 differing ability
 other (specify)
2. Elsewhere (back home, etc)
 this year
 in the past
It was with:
 friend
 date/acquaintance
 someone I don’t know
 family member
******************************************************************************************
Please estimate how much your problems are
affecting the following areas of your life:
Academic
 No interference
 Mild interference
 Moderate interference
 Severe interference
Social
 No interference
 Mild interference
 Moderate interference
 Severe interference
Please indicate the times that are NOT AVAILABLE for a counseling appointment by
marking an “X” in the boxes below:
9:00
Monday
Tuesday
Wednesday
Thursday
Friday
10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00