Race/Ethnicity (Check all that apply):
Date:_____________________________ RIT/University ID #_____________________________________________
Have you been to RIT Counseling and Psychological Services before? □ Yes □ No
Who referred you to Counseling and Psychological Services?
□ Friend □ Family □ Self □ Faculty/Staff □ Conduct □ Other
First Name:______________________________ MI:_______ Last Name:____________________________________
Preferred Name:____________________________________________________________________________________
Local Phone_____________________________ Email: ________________________________________________
Any reason we should not contact you via phone or email?___________________________________________________
Local Address______________________________________________________________________________________
(include residence hall and room number or apartment / off campus address)
Home (Permanent) Address___________________________________________________________________________
Date of birth: ______________ Age: ___ Gender Identity:
□
Woman □ Man □ Transgender □ Self-Identify
Race/Ethnicity (Check all that apply): □ African American/Black □ American Indian or Alaskan Native
□ Asian American/Asian □ White (non-Hispanic)
□ Hispanic/Latino(a)
□ Multi-racial
□ N ative Hawaiian or Pacific Islander
□ Other:____________________________
Check all that apply to you: □ Deaf/Hard-of-Hearing
□ International Student
□ Student-Athlete
□ Greek Member
□ Transfer Student
□ Military Veteran
If yes, preferred communication?________________
If yes, which country?_________________________
If yes, which sport?___________________________
If yes, which organization?_____________________
If yes, which school?__________________________
If yes, which branch?__________________________
Academic Classification (Year): □ First □ Second □ Third □ Fourth □ Fifth □ Graduate Student
Current GPA:_________ Total Credit Hours:_________ Major:____________________________________________
Enrollment status:
□
Full-time □ Part-time □ Non-matriculated
□
□
Phone: ___________________________________ Relationship to you: _____________________________________
Briefly describe why you chose to seek Counseling and Psychological Services:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

□ African American/Black
□ Hispanic/Latino(a)
List members of your immediate family, caregivers, or primary support system.
Relationship Name Relationship Name
Are you currently receiving or have you previous received mental health services? □ Yes □ No
Please list dates and locations:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please list any medical conditions you have or believe you might have:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please list any medications that you are currently taking:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please check all the RIT Supports Services you have used:
□ Academic Support Center□ Center for Women and Gender □ Disability Services
□ English Language Center
□ International Student Srv.□ Leadership and Community Service □ Spectrum Support □ Student Wellness
RIT Counseling and Psychological Services (CaPS) provide short-term personal counseling (individual, couples, and groups), consultation, and referral services, which are confidential and require no additional fee. Only currently enrolled
RIT students are eligible for services. Depending upon the nature of your concern, current service demands or other circumstances, your counselor may refer you to another health care provider who can better meet your needs.
Confidentiality
Records maintained by Counseling and Psychological Services (CaPS) are considered medical records and protected health information. As such, your counseling records are kept separate from all other student records. This means what you tell or otherwise share with your counselor and the counseling staff will remain confidential. Consultation with individuals or organizations outside CaPS, including RIT faculty and staff, family, or friends requires your written consent. There are, however, some exceptions and limitations to confidentiality as required by law. Please carefully review the Client Consent Form and speak with your counselor if you have any questions.
I have read the Client Consent Form and agree to the terms of Counseling and Psychological Services (CaPS).