Health and Wellness Center
Counseling Intake Form
Please complete this form and bring it with you to your initial counseling session.
Today’s Date:
Appointment Date:
Full name:
Preferred Name:
Local address/Residence Hall location:
Permanent address/Hometown:
Age:
Year of study: First Year Sophomore Junior Senior Other
Sex: Male Female Other
Gender: Woman
Gender
Pronouns:
Man
Transgender FTM
She/Her/Hers
He/Him/His
Transgender MTF
They/Them/Theirs
Questioning
Ze/Zir/Zirs
Other
Other
Race/Ethnicity: American Indian/Alaska Native African American/Black Asian Caucasian/White
Hispanic/Latino Native Hawaiian/Pacific Islander Multiracial Other_____________________
Citizenship:
Are you an international student? Y N
Were you referred to counseling services? Y N If yes, who referred you?
State reason(s) for counseling and primary area(s) of concern at this time:
Describe history of your concern(s):
AREAS OF CONCERN
On the next two pages, check all concerns you currently experience and then mark your level of distre
ss for each concern. You may write specific information below any of your concerns to help your couns
elor better understand what it going on for you at this time.
✔
Concern
Relationship Difficulties
Family Problems
Depressed Mood
Suicidal Thoughts, Feelings
Anxiety
Stress, Psychosomatic Symptoms
Sleep Problems
Emotional Regulation
Academic Difficulties
College Adjustment
Cultural Adjustment
Low Self--‐Esteem
Grief, Loss
Existential, Spirituality
Eating, Weight, Body Image
Addictive Behavior
Cutting, Self--‐Injury
Sexual Assault, Harassment
Sexual Orientation
Gender Identity
Sexual Health
Mild
Moderate
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2
Serious
Severe
✔
Concern
Social Skills, Ability to Connect
Attention, Concentration
Physical Disability
Medication
Anger Issues
Unique Perceptions, Sensations
Extreme Elevations in Mood
Trauma
Harm from Others
Harm to Others
Other:
Other:
Mild
Moderate
Serious
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AREAS OF IMPAIRMENT
Mark any areas of your life you feel are impaired by your current concerns:
Class performance/attendance
Family
Work
Physical health
Romantic relationships
Spirituality/religion
Friendships
Financial
Roommates
Other:
SOCIAL LIFE
Describe current social life including relevant social history:
Living situation (mark all that apply):
On campus
Room/Housemates
Off campus
Partner/Spouse
Alone
Parents
3
Other:
Severe
Indicate sexual orientation:
Heterosexual
Bisexual
Gay
Lesbian
Pansexual
Questioning
Asexual
Other:
Relationship status:
Single
Committed
Dating
Married
Open relationship
Other:
List any specific social concerns:
ACADEMIC HISTORY
Are you a transfer student? Yes No
What schools have you attended? (other colleges, high school, private/public, study away, etc.)
Academic major:
Current GPA:
Current credit load:
Courses this semester:
Minor (if any):
Current academic performance: Excellent Good Fair Poor
Are you currently on academic or social probation or warning? Yes-‐ Academic Yes-‐ Social No
Reasons for probation:
Do you have an identified learning disability? Yes No
Please specify
type
of
disability
and
accommodations:
WORK AND ACTIVITIES
Current Job:
Clubs or activities:
Arts or athletics:
Hours per week:
Hours per week:
Hours per week:
4
FAMILY HISTORY
Were you adopted? Yes No Not Sure
Please indicate your family relationships in the chart below.
Family member’s name
Relationship to you
Age
Occupation
Location
Martial Status
Describe any known history of mental illness or addiction in your family:
Have you experienced abuse? Yes No Not Sure
Please specify type of abuse and age when it occurred:
HEALTH HISTORY
How would you describe your overall physical health? Excellent Good Fair Poor
Have you had any chronic conditions, major illnesses, serious injuries, or significant head trauma?
Yes No Not Sure Please specify:
Do you have a diagnosed pre-‐‐existing mental health condition?
Yes No Not Sure Please specify:
Do you have any previous experience with counseling?
Yes No Not Sure Please specify:
Do you regularly take any medications for psychological difficulties?
Yes No Not Sure Please specify:
Are you currently taking any other medications?
Yes No Not Sure Please specify:
Have you ever been hospitalized for psychological problems?
Yes No Not Sure Please specify:
Have you ever attempted suicide?
Yes No Not Sure Please specify:
Have you ever received treatment for disordered eating or a diagnosed eating disorder?
Yes No Not Sure Please specify:
5
Do you suspect you have a problem with an eating disorder?
Yes No Not Sure Please specify:
Do others suspect you have a problem with an eating disorder?
Yes No Not Sure Please specify:
Please indicate your frequency and quantity of use for each substance.
Substance
No current
use
Once
per month
1--‐3 times
per month
Once per
week
2--‐3 times
per week
4--‐5 times
per week
Alcohol
Marijuana
Other:
Other:
Other:
If you drink alcohol, how many drinks do you typically have in one sitting?
Have you ever received treatment for alcohol, marijuana, or other substance use?
Yes No Not Sure Please specify:
Do you suspect you currently have a problem with alcohol or drug use?
Yes No Not Sure Please specify:
Do others suspect you have a problem with alcohol or other drugs?
Yes No Not Sure Please specify:
Do you use caffeine? Yes No Not Sure
Do you use tobacco? Yes No Not Sure
Do you exercise?
Yes No Not Sure
Are you satisfied with the quality and quantity of your sleep? Yes No Not Sure
How much sleep do you get every 24 hours?
Is there anything else you would like your counselor to know?
Thank you for completing the Intake form.
6
6 or more times
per week
7