INTAKE INFORMATION
Broene Counseling Center
Calvin College
Date _________________________
The information you provide is STRICTLY CONFIDENTIAL and DOES NOT become part of your academic record.
Information can be revealed only with your permission or in extreme emergencies, such as preventing injury to you or to others.
Name ________________________________________________________
Student ID # _____________________________
Phone _________________________________________________________________
Email address ___________________________________________________________
Local address ___________________________________________________________
OK to phone?  Yes  No
OK to leave message?  Yes  No
OK to text?  Yes  No
OK to email?  Yes  No
OK to send mail?  Yes  No
___________________________________________________________
Hometown _____________________________________________________________
Date of birth ______/______/______ Age _________
Gender  Male  Female
Relationship status  Single  Married
Ethnic identity (Optional)
 I am an international student. My country of citizenship is ___________________________________
 I am a U.S. citizen or permanent resident. I identify my ethnicity as (please check one or more)
 American Indian or Alaskan Native
 Asian
 Black or African American
 Hispanic or Latino(a)
 Multi-ethnic _____________________________________
 Native Hawaiian or Other Pacific Islander
 White
Current academic status  First-year  Sophomore  Junior  Senior  Grad Student
What is your major? _________________________________How many credits are you taking this semester? __________
What is the average number of hours you work per week during the school year (paid employment only)? _____________
Have you documented a diagnosed disability with the office of Disability Services?
 Yes  No
List medications you are taking (and dosages)________________________________________________________________
Who referred you to our office? (please check all that apply)
 Self
 Another student
 RA/RD
 Online screening (BCC website)
 Parent
 Judicial Affairs
 Professor
Other ___________________________________
Have you been seen at our office in the past?  Yes  No
If yes, who was your counselor? ______________________________
Counselor you are seeing today  Amanda  Andrea  Cindy  Dan  Irene  Michelle  Rick  Sarah
TURN OVER
Never
Please indicate if and when you have had the following experiences:
(check all that apply)
Prior to
college
After
starting
college
Attended counseling for mental health concerns
Taken a prescribed medication for mental health concerns
Been hospitalized for mental health concerns
Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, pulling hair,
etc.)
Seriously considered attempting suicide
Made a suicide attempt
Considered seriously injuring another person
Been concerned about your alcohol or drug use
Had unwanted sexual contact(s) or experience(s)
Experienced harassing, controlling, and/or abusive behavior from another person
(e.g., friend, family member, partner, or authority figure)
Experienced a traumatic event
_______________________________________________________________________________________________________
For Office Use Only
Code __________________________________________________
New File
Yes
No
DX ___________________________________________