Please complete and hand this form with the attached questionnaire to the Receptionist in advance of your first meeting.
UNIVERSITY COUNSELLING SERVICE - INITIAL INTERVIEW
============================================================================
Today’s date:
Appt. date:
Time:
With:
----------------------------------------------------------------------------------------------------------------------------- -------Your Name:
Date of Birth:
Gender:
------------------------------------------------------------------------------------------------------------------------------------Local Address:
--------------------------------------------------------------------------------------------------------------Student e-mail:
Telephone:
Mobile:
----------------------------------------------------------------------------------------------------------------------------- -------(Please note contact is generally by e-mail)
Home address if Applicable:
--------------------------------------------------------------------------------------------------------------School:
Dept.:
Course:
Year:
--------------------------------------------------------------------------------------------------------------Undergraduate
Postgraduate
Staff
Non Student
Exchange
(Please circle all those that apply)
--------------------------------------------------------------------------------------------------------------Registered with the University Health Centre?
Yes / No
If NO, please give the name and address of your doctor:
--------------------------------------------------------------------------------------------------------------Please mark clearly the TIMES THAT YOU ARE AVAILABLE during the current term
Times
Unfortunately at peak times of the year
restricted availability mean you may
have to wait for some while.
Monday
Tuesday
Wednes
Thursday
09.00 – 10.00
10.00 – 11.00
11.00 – 12.00
Please therefore indicate as
much availability as possible.
12.00 – 01.00
You may make an appointment:
02.00 – 03.00
03.00 – 04.00
Online via Sussex
Direct/study/counselling
04.00 – 05.00
e-mail:
counsellingreception@sussex.ac.uk
by telephone: 01273
01.00 – 02.00
678156,
05.00 – 06.00
06.00 – 07.00
07.00 – 08.00
08.00 – 09.00
or in person: our opening hours are
9.00–1.00pm and 2.00–5.00pm
University
Counselling
Services
Health Centre Building
University of Sussex
Falmer, Brighton
BN1 9RW
Direct line 01273 678156
counsellingreception@sussex.ac.uk
www.sussex.ac.uk/counselling
Friday
What brings you to counselling now?
(Please give as much information as you can)
----------------------------------------------------------------------------------------------------- --------------------------------------------------------
Please tell us something about your family background.
Have you ever had any counselling before?
(Please give details)
Do you have any health problems?
Are you on any medication? If so what?
Over the last week:
How effective have you been at keeping up with your course and assignments?
0%
Not at all
Effective
10%
25%
50%
75%
100%
Most effective
75%
100%
Very likely
How likely do you think you might drop out of University?
0%
Not at all
likely
10%
25%
50%
----------------------------------------------------------------------------------------------------------------------------- --------------------------------
How many units of alcohol do you drink per week? 1
(please circle)
1 One
0
unit = ½ pint of beer, small glass of wine, 1 shot.
1-10
11-20
20-30
30-40
40-50
50+
-------------------------------------------------------------------------------------------------- -----------------------------------------------------------
Would you prefer to see:
Male / Female therapist?
No preference?
--------------------------------------------------------------------------------------------------------------------- ----------------------------------------
How did you hear of our service?
Academic Advisor

GP

Publicity

Residential Advisor

Chaplain

Friend

Student UNION

Student Life Centre

Family

Disability/ Mental Health

Other
 please supply ____________________
THANK YOU FOR COMPLETING THIS FORM
UNIVERSITY COUNSELLING SERVICE (UCS)
INFORMATION FOR CLIENTS
University Counselling Service is committed to the principles of equal opportunities and open
access. We adhere to the ethical guidelines of the professional bodies to which we belong, copies
of which are available at Reception.
CONFIDENTIALITY
UCS provides a safe and confidential service. Confidentiality is held within the Counselling Team
(and within the constraints of the law).
UCS and the University are required to make statistical returns for information purposes.
The University may be informed that you have attended though your reasons for attending and
what was discussed remain confidential
EVALUATION
UCS uses a standard evaluation system. This has been developed to help providers of other
psychological and counselling services to develop and deliver the best possible services to clients.
As part of the system, all clients are asked to complete a brief questionnaire before, during and
after contact with the service. The information helps us to understand your concerns and the
degree to which we have been able to help.
About our evaluation:

The first questionnaire is attached. It asks questions about how you have been feeling over
the past week.

Completing the questionnaire is entirely voluntary and you are free to choose whether or
not you wish to complete it. However the more people who complete the form, the more
comprehensive the information is for improving the service.

The information from the questionnaire will be treated as strictly confidential.
No names are used and no one outside the Counselling Team will have access
to your responses.
ENQUIRIES
If you have any queries or require a copy of our complaints procedure, please ask the Receptionist
during opening hours currently 9.00 – 5.00 on weekdays or leave a message on the answerphone
or via e-mail outside of these hours
University Counselling Service
Health Centre Building, University of Sussex,
Falmer, Brighton, BN1 9RW.
(01273) 678 156 email: counsellingreception@sussex.ac.uk