Methodist University
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0,3,iff]i'J?ff::?i'ifiTf:.1i::Tii3'1ilffiil:1":'l?:TP,J'y,."*"?#;f,-^e services you request and in developing and improving our services. All the information you provide will be kept confidential in accordance with the highest ethical standards of the counseling profession.
PLEASE PRINI
Today's date:
First, Middle and Last name Preferred Pronoun
To be fllled out by Counselor lUlaior
Goncern:-
Previous
Gontacfi_
Date of Birth
Residence Hall Name, Room Number MU PO Box Number ....or local mailing address, if living off campus
Best Phone Number To Reach
College major or Undecided School Year
(Fr, So, Jr, Sr, Grad School, PA $chool)
Home State MU Student Athlete? What sport?
Greek Life?
Which Chapter?
Relationship status ($ingle,Married,
Divorced, Widowed, Partnered)
Please check the answers which best describe your situation, CHECK ALL THAT APPLY:
MU Enrcllment
_
Full time residential student
_
Commuter day student
_
Evening college student
_
Staff/faculty member
Gender: *M
Other:_
Ethnic Origin
(We need this info to prove that we help allpeople)
_
White/Caucasian
_
Black/African American
_
Hispanic/Latino American
* Asian American
_ lnternational Student
From where?_
Other
Who suggested that you
_
Academic advisor
_
Professor
_
ParenUfamily member
_
RA/RC
_
Dean/Assistant Dean
_
Coach
_
Minister
_
Friend
_
Fellow Student
Self
us:
How did you hear about our serviceg?
_
Orientation Presentation
_
$tudent Handbook
_
Class room discussion
_
Professor
_
Flyer in classroom
*
MU Website
_
Friend/family member
_
Fellow Student
_
College staff member
_
I sought out the information myself
Will being a participant here poeeihly help you to remain at
MU?
(Please check all that apply)
_
Yes. A college official has required me to come
_ Yes.
My parent or other family member insists that
I come.
_
Yes. My situation is stressful enough that talking it over is essentialto me.
I have been in counseling before and know the value.
_
Not sure... I am checking this out to see if it will help.
_ No. I need to be convinced that this sort of thing will be helpfulto me.
I am looking for help with...
Check all that apply:
_Learning problems
problems
_Feeling depressed
_Feeling homesick
_Relationship problems
_Pressure from parents
_Gender issue
_Sexual orientation concern
too much
_Divorce recovery
_Someone else's concern about my drinking
_Family problems
_Alcohol/drug problem
_Concern about someone close
_Break-up of a relationship
of focuVconcentration
_Having trouhle getting out of bed
_Having trouble sleeping
_Eating/appetite/weight concerns
*Overwhelmed with stress
_Decision about career or major
problems/making choices
_Class/academic stress
_Decision about a relationship
_Couples counseling
_Getting or staying motivated
_
Sex issue
_
Past abuse or violence
of something special to me
*Roommate conflicts
_Medication management
bereavement counseling
_
Something not mentioned