CWU: Student Counseling Clinic
Name
SUPPLEMENTARY CLIENT INTAKE FORM
(Please Print):
_____________________________________
Date: _______________
In your own words, what are you struggling with that prompts you to seek counseling right now?
Describe special interests, hobbies, or activities that you enjoy and that you have been avoiding as a result of
what you have been struggling with:
What are the three things that you value the most in your life right now?
What change(s) would have to happen in order for you to improve your life?
1. What is your sexual orientation?
 Heterosexual  Lesbian  Gay  Bisexual  Questioning
2. How important are religious/spiritual matters to you?
 Not Very  A Little  Moderate  A Lot
3. Are you currently affiliated with a religious/spiritual group?
Yes
No
4. Are there any special, unusual, or traumatic circumstances that affected you growing up
(e.g., abuse, neglect, violence, family violence, and/or assault)?
Yes
No
5. Are you currently involved in any legal actions (either as a defendant or plaintiff)?
Yes
No
6. Do you have any past history of criminal charges or civil actions?
Yes
No
8. Do you have any disabilities we should know about, or that might impact counseling?
Yes
No
9. Are you currently being evaluated or treated for any physical complaints, pains, or illnesses?
Yes
No
10. Do you have any history of out-of-the-ordinary illnesses?
Yes
No
11. Do you have any health-related concerns that you are not currently being treated for?
Yes
No
7. How would you characterize your current health?
 Excellent  Good  Fair  Poor
12. Please check whether you’ve experienced any of the following in the past couple of weeks:


Sleep difficulties
Appetite changes
 Lack of interest in activities  Feelings of guilt/remorse  Poor energy
 Difficulty concentrating  Reduced/increased activity level  Weight gain/Loss
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Please list all prescribed medications and any over-the-counter medications or supplements that you take.
Medication
Over-the Counter Medication or Supplement
Dose
Prescribed by
How often is it used?
13. Have you ever been in trouble as a result of drinking or substance use (e.g., minor in
possession, DUI, DWI, drunk and disorderly, etc.)?
Yes
No
14. Do you think your substance use is interfering with your school performance, social
relationships, job performance, or other responsibilities?
Yes
No
15. Even if you aren’t concerned, has anyone else ever thought that you should stop or reduce
your use of substances?
Yes
No
17. Have you ever seen a mental health provider for services (e.g., school counselor, social
worker, mental health counselor, psychologist, or psychiatrist)?
Yes
No
18. Is there anyone in your immediate family with a history of psychiatric illnesses (e.g.,
depression, anxiety, substance abuse, schizophrenia, bipolar disorder, etc.)?
Yes
No
19. Do you currently have, or in the past couple of weeks have you had, thoughts or feelings
about ending your life?
Yes
No
20. Have you felt hopeless lately, like things wouldn’t improve or get better?
Yes
No
21. Have you ever attempted suicide?
Yes
No
22. Has there ever been a time when people thought you were either too thin or losing too
much weight?
23. Have you ever felt out of control and gone on eating binges during which you ate an
abnormally large amount of food?
Yes
No
Yes
No
24. Has there ever been a time, lasting at least a few days, during which you felt hyper,
charged up with energy, and you thought this was different from your usual self?
Yes
No
25. Before attending college, were you ever identified as having a learning disability or as
having an attention deficit (ADHD)?
Yes
No
26. Are you currently employed, even part-time?
Yes
No
27. Have you ever served in the military service, or consider yourself a veteran?
Yes
No
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