Intake Form

Please print a copy of this intake form as soon as you complete it. You will need to bring it with you on your first visit to the Counseling Center. This form will reset itself once you press the Submit button. If not, please click the Reset button.

File # ________

Name:

(First) (mi) (Last)

Today's Date:

Local Address:

(Street) (City) (State) (Zip)

Local Phone: Other Phone:

E-Mail:

If we should need to contact you do you have any special requests?

Yes No

How did you learn of our services (check all that apply)?

Friend/Family Member Faculty/Staff

Workshop/Presentation Disability Services

Phone Book Student Health Services Web Site

Other (specify)

Date of Birth Gender:

Ethnicity:

Student ID Number (Not Social Security#)

International Student? Yes No

If Yes, from where?

Class: F SO J S G

Other

Currently Enrolled? Yes No

Number of Credit Hours:

Major: Transfer? Yes No

If yes, from where?

Are you currently on academic probation? Yes No

Employed? Yes No If yes, what is your job?

Are you married or partnered? Yes No

What brings you to the Counseling Center?

Do you have a preference for which counselor you see?

Please check the number that tells us how urgent your concern(s) are:

1 2 3 4 5 6 7

Not at all urgent Extremely urgent

Treatment and Medical History

Are you currently receiving or have you previously received services from a counselor/mental health professional?

If yes, please list provider name and date(s) of treatment:

Have you ever been hospitalized for emotional or drug/alcohol treatment? If yes, please describe the circumstances:

Please list any medical conditions that you have or believe you might have:

List any medications you are currently taking:

Name of Health Care Provider/Treating Physician:

Do you have health Insurance? Yes No

CLIENT RIGHTS

You have the right top be treated with dignity and respect without regard to your race, color, religion, national origin, gender, age, sexual orientation, or disability.

You have the right to have your counselor explain the way in which your confidential mental health information will be handled and the limitations of confidentiality.

You have the right to request a specific counselor, request a different counselor than the one assigned to you, or ask for a second opinion.

You have the right to receive an appropriate referral for community mental health services if you request one or if your needs exceed what we are able to provide you.

You have the right to work collaboratively with your counselor in establishing treatment goals.

You have the right to ask questions about your counselor's qualifications, credentials, and theoretical orientation, as well as any counseling and testing techniques/procedures utilized.

You have the right to refuse or terminate treatment.

You have the right to review with your counselor the records in your personal file maintained by the Counseling Center, including diagnosis and test results.

You have a right to a copy of records generated by our office. Typically, you will be asked to meet with your counselor to review the records before they are released to you.

CLIENT RESPONSIBILITIES

You should make every effort to arrive on time for appointments.

You should notify the Counseling Center if you are unable to keep a scheduled appointment. Notification allows us to make appointment time available to other students. Clients who consistently miss appointments without notification may have those services terminated or restricted.

You are expected to arrive for appointments without being under the influence of drugs or alcohol.

I have read and understand these rights and responsibilities.

Signature: Date:

Behavioral Health Questionnaire - 20 (BHQ-20tm)

Please answer these questions as they relate to the past two weeks.

1. How distressed have you been?

Extremely distressed (0)

Very Distressed (1)

Moderately Distressed (3)

A little bit distressed (4)

Not at all distressed (5)

2. How satisfied have you been with your life?

Not satisfied at all (1)

Mildly satisfied (2)

Somewhat satisfied (3)

Satisfied (4)

Very satisfied (5)

3. How energetic and motivated have you been feeling?

Not at all energetic and motivated (0)

A little bit energetic and motivated (1)

Somewhat energetic and motivated (2)

Energetic and motivated (3)

Very energetic and motivated (4) WB= ______

In the past two weeks how much have you been distressed by:

4. Feeling fearful, scared: