First Name* must provide value
Middle Initial
* must provide value
Last Name* must provide value
Preferred Name and/or Nickname
Campus Email* must provide value
Student ID Number (found above bar code, NOT Social Security #)* must provide value
Local Address / Residence Hall and Room #* must provide value
Phone Number* must provide value
Is it okay to call the number provided?* must provide value
Yes
No
Email you check most frequently* must provide value
Is it okay to email the email address provided?* must provide value
Yes
No
Gender* must provide value
Age* must provide value
Date of Birth* must provide value
Today M-D-Y
Race / Ethnic Background* must provide value
Black/African American
Native American or Alaskan Native
Asian American
Asian
Caucasian / White
Hispanic / Latino
Native Hawaiian or Pacific Islander
Multi-racial
Prefer not to say
Sexual Orientation* must provide value
Bisexual
Heterosexual
Lesbian/Gay
Questioning
Self-Identify
Please specify your Sexual Orientation
Preferred Pronouns
Relationship Status* must provide value
Single
Married
Divorced
Engaged
Dating
Living Together
Separated
Widowed
Self-identify
Please Specify your Relationship Status
Children* must provide value
Yes
No
How many children do you have?
Military Active
Reserves
Branch Air Force
Army
Navy
Marines
Coast Guard
Vetran* must provide value
Yes
No
Military Dependent* must provide value
Yes
No
Classification Freshman Sophomore Junior Senior Graduate Student International ESL
Major
Minor
Current GPA
Are you currently Employed?* must provide value
Yes
No
How many hours do you work per week?
Housing Situation On Campus
Off Campus with Family
Off Campus with Partner
Off Campus with Roommates
Off Campus Living Alone
Who Referred you to counseling? Faculty
Staff
Student
Family
Friend
Partner/Spouse
Physician
Roommate
Other
Please Specify who referred you to counseling
Have you attended counseling in the past?* must provide value
Yes
No
Please provide the name of the counselor and/or clinic
Are you taking any medication?* must provide value
Yes
No
What medication are you taking, and who prescribed it?
How often do you drink alcohol?* must provide value
0 times per week
1-2 times per week
3 or more times per week
Average amount of alcohol consumed
How often do you use other drugs? 0 times per week
1-2 times per week
3 or more times per week
Average amount of drug usage
Negative consequences of using drugs
Names of family members (Parents and sibling) / Significant Others (Partners and Children)
In your own words, please describe your relationship with family/significant others/friends
Please state, in your own words, what you would like to discuss with a counselor* must provide value
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship to you
How serious do you consider your present concerns* must provide value
Not at all
Mildly
Moderately
Highly
How motivated are you to resolve your concerns* must provide value
Not at all
Mildly
Moderately
Highly
How optimistic are you that your concerns can be resolved* must provide value
Not at all
Mildly
Moderately
Highly
How long have these problems persisted?
What are your goals for counseling (i.e., what do you want to occur as a result of counseling?). Please be as specific as possible.* must provide value
Is there anything else you would like for your counselor to know about you?
Please read this list and check the items that describe you or your situation Adjustment to college
Academic concerns
Feeling unmotivated
Unsure of career choise
Financial problems
Procrastinating
Feeling helpless
Headaches
Disorganized
Eating less/more
Spiritual problems
Isolating self
Feel that others do not like me
Skipping class
Feeling hopeless
No close friends
Romantic problems
Feeling anxious
Tightness in chest
Compulsive
Nervous/Worrying too much
Anger
Thoughts of harming another person
Feeling guilty
Grief/Loss
Abortion
Loss of interest in things Lonely
Difficulty expressing emotions
Worried about body image
Difficulty sleeping
Student conduct concerns
Uncertain about sexual identity
Use of drugs/alcohol
STD/HIV/AIDS
Parental conflict
Family problems/pressure
Emotional abuse
Physical abuse
Irritability
Dizziness of ligh headedness
Sudden changes in personality or behavior
Feeling disconnected
Vomiting
Loss of memory
Health worries
Feeling unattractive
Experiencing mood shifts
Trust issues
Numbness/tingling
Sleep problems/nightmares
Out of control
Thoughts or worthlessness
Stressed
Feeling numb
Roommate problems
Afraid
Legal concerns
Feeling depressed/sadness
Discouraged about the future
Feeling inferior
Afraid of making mistakes
Failure or rejection
Recklessness
Feeling unlovable
Sexual matters
Acting aggressively
Sexual assault/Rape
Impulsive
Uncertain about gender
identity
Unable to concentrate
Little interest or pleasure in doing things* must provide value
Not at all
Several Days
More than half the day
Nearly every day
Feeling down, depressed or hopeless* must provide value
Not at all
Several Days
More than half the day
Nearly every day
Consent for Counseling and Acknowledgement* must provide value
By checking this box, you to indicate that you have read, understood, and completed this form to receive counseling services in the Student Health & Wellness Center.
Please sign below to indicate that you have read, understood, and accept the information and conditions contained in this document.* must provide value