IUMW Counselling Unit
COUNSELLING SESSION INTAKE FORM
FORMS/SSC-04/ICU/CSI
Note: All information that you provide in this form will be treated as strictly confidential.
Demographic information
Name
: ____________________________ Gender
: ____________________
_____________________________ IC/Passport no.
: ____________________
Date of birth
: ____________________________ Tel no.
: ____________________
Email address
:
Faculty
: ____________________
Study programme
: ____________________________ Relationship status
: ____________________
Emergency contact – In case of emergency, please contact:
Full name
: ____________________________ Relationship
: ____________________
_____________________________ Tel no.
: ____________________
Present address
: ________________________________________________________________________
_________________________________________________________________________
Checklist – Please tick all from the following that concerns you:
Adjustment to new culture
Anger
Anxiety
Avoidance of contact with others
Career plans
Change in class participation
Change in classroom attendance
Change in friends
Change in student/lecturer rapport
Cheating
Class performance
Concentration
Confidence
Defensive
Deliberately hurting myself
Depression
Difficulty beginning a task
Difficulty completing tasks
Difficulty maintaining attention
Does not accept responsibility for own behaviour
Drop in grades/points
Easily distracted
Easily frustrated
Easily influenced by others
Fighting/physical abuse
Full of regrets
Others, please describe:
Have you received counselling before?:
Gender identity
Grief & loss
Hypersensitive
Inappropriate responses
Incompetent
Inconsistent daily work
Interrupts and distracts class
Irresponsibility, blaming, lying
Lack of energy
Lack of motivation; apathy
Lacks self-control
Late for classes
Not fulfilling responsibilities
Pattern of early morning tiredness
Procrastination
Racial harassment
Relationship
Sexual harassment
Stress
Sudden changes in mood
Thoughts of killing myself
Time disorientation
Unable to sleep/insomnia
Unusually aggressive toward others
Unusually shy or withdrawn
Work performance
Yes
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No
IUMW Counselling Unit
COUNSELLING SESSION INTAKE FORM
FORMS/SSC-04/ICU/CSI
TO BE FILLED IN BY THERAPIST/COUNSELLOR
Presentation of Problem (Client’s own words, why referred, indicate symptoms/ overt action)
History of Present Problem (Severity, duration, situation, intervention attempted)
Medical, Psychiatric History and Substance Abuse (Medications, hospitalizations, family history,
health appraisal, referral needs, rehabilitation, etc.)
Early Education/Employment and Developmental History (Education background, job history,
childhood history, significant early events, social/cultural factors, etc.)
Marital, Family Relationships and Love Issues (Abusive, withdrawal, silent treatment, etc.)
Client’s Strengths and Support System (Positive appraisal from family members, friends, lectures,
strangers, boss, colleagues, etc.)
Spiritual/Religious Background (Religious background, personal faith, conflicts, etc.)
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IUMW Counselling Unit
COUNSELLING SESSION INTAKE FORM
FORMS/SSC-04/ICU/CSI
Recommended Treatment Type:
Individual
Group
Couple
Family
Other Referral(s) made outside of IUMW Counselling Unit, if any:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
CANCELLATION POLICY
If you need to cancel or postpone the appointment due to unavoidable circumstances, please do
give the Counsellor at least 24-hour/1-day notice.
CONFIDENTIALITY
All information gathered by the Counsellor during the provisions of the counselling services will
remain strictly confidential, shared only on need-to-know basis and only with relevant stakeholders.
By signing, you are giving a written consent for your information to be shared outside of the
IUMW Counselling Unit for this purpose.
In some specific situations, Counsellor may be required to share information without the client's
prior written consent. Common exceptions include:
1. In order to protect the patient or the public from serious harm — if, for example, a client
discusses plans to attempt suicide or harm another person.
2. Counsellor is required to report ongoing domestic violence, abuse or neglect of children, the
elderly or people with disabilities. (If an adult discloses that he or she was abused as a child
in the past, the Counsellor typically is not bound to report that abuse unless there are other
children who continue to be abused.)
3. Due to a court order. This might happen if a person's mental health came into question during
legal proceedings.
……………………………..……………………………………………
Client’s IUMW I.D. No.:
Date:
……………………………..……………………………………………
Counsellor name:
Date:
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