Cambridge University Student Counselling Service
Pre-Counselling Form
PART A
The information in Part A is requested for record-keeping and statistical purposes; it will not
be used outside the Service in any way that identifies individuals. If you are completing this
form electronically, you can type into the grey areas, which will expand to fit your answers.
The ‘TAB’ key will automatically take you from one question to the next. All the
information you provide is covered under the terms of the Data Protection Act 1998.
Surname
First Name
Gender
Date of birth
Nationality say
Ethnicity
– College
Staff – University
Are you:
Other (please specify):
Status:
-time
Part-time
If graduate, university of 1st degree
College:
Dep’t / Faculty:
Subject:
Level (e.g. BA,
Current year of study (on this course):
2
4
5
Do you expect to graduate this year?
Address (if different from College)
Telephone number
Is it OK to leave a message on your phone?
Email address
Can we contact you by email?
Which is the best way of contacting you?
Phone
Referral: Who suggested that you came to see a counsellor?
No-one (self-referral)
Friend
DoS / Supervisor
Other academic
Have you used this Counselling Service before?
1
3
6 or more
Cambridge Doctor:
Current medication, if any:
Other forms of help you have used previously
or currently for related issue(s):
GP
Counsellor
Psychologist
Psychotherapist
Psychiatrist
Other kind of specialist help
Previously
Currently
Availability
Please fill in the boxes below, allowing for travel time: ‘Y’= available; ‘N’ = not available.
We will try to offer an appointment when you are available but may offer non-preferred
times to reduce the waiting period.
Very restricted availability is likely to delay counselling.
Term time:
9am 10
11
12
1pm 2
3
4
5
6
Mon
Tue
Wed
Thu
Fri
Are you in Cambridge during the next vacation?
If so, please indicate the likely dates:
Please sign to indicate that you have read the ‘Information for anyone thinking about
counselling' (available at: www.counselling.cam.ac.uk/students.html)
Date
Signed
(or type name)
Please continue to Part B
---------------------------------------------- --------------To be filled in by the Counselling Service:
Date form returned:
Date acknowledged:
Appointment arrangements made:
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PART B
The information you provide will help us to understand your needs and arrange for you
to see an appropriate counsellor, so it is useful to have some information about the
problem. The questions are intended to be thought-provoking, but you do not need to
give long answers or address every sub-question if it is irrelevant; it is also OK to put
“you would prefer to talk about this in person” if it is difficult to write about.
This information will be treated confidentially.
1. Your reasons for approaching the Counselling Service
Please describe what has led you to your seek counselling now. How long has this been a
problem for you — and what other help have you had with it? How do your current
difficulties affect you?
2. What are you hoping for from counselling?
What would you like to gain from counselling now? How would things be different if the
difficulties were resolved?
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3. On a scale of 1 – 10 (with 10 being the most serious), how seriously is this affecting:

Your quality of life in Cambridge

Your academic performance
4. Coping
How have you been coping with this problem until now?
What support do you have in your life (e.g. family, friends, College, social activities)?
Do you have any difficulties with alcohol, drugs or food?
At your worst, do you ever feel like harming yourself or others?
5. Contributing factors
Sometimes we are aware of ways in which we may be contributing to a problem even though
it was not of our making. If you think this applies here, please say a bit more.
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6. Background
If it seems relevant, please give any ideas you may have had about the origin of the problem.
7. Much of our work involves workshops and groups of various kinds.
Please indicate whether these might interest you (more details are on our website at
www.counselling.cam.ac.uk/groups.html)?

Structured groups with a focus on practical strategies:

Ongoing counselling groups:
8. Is there anything else that you think is important which we should know?
Please take or post to the University Counselling Service, 2-3 Bene’t Place, Lensfield Road.
If you have completed the form electronically, first save it and then email it as an attachment
to: reception@counselling.cam.ac.uk but PLEASE NOTE that we cannot guarantee that
messages sent by email are confidential.
Thank you.
(StudentPreCouns rev 15/8/12)
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