Counseling- Intake Form

Counseling Services

Intake Form
If you need immediate assistance with a crisis situation, please click this link for a list of 24/7 emergency resources
Name *

First Name Last Name
Today's Date: *

Month Day Year
Date
Student ID # *
Date of Birth *

Month Day Year
Date
Please check all the reasons that you have come in:

ADD/ADHD Eating disorders/body image Sexual assault/harassment Academic/faculty concerns Family Sexuality Adjustment/transition Grief/Loss Significant other Alcohol/drug use Identity development Sleep problems Anxiety/stress Physical abuse Social life/making friends Childhood sexual abuse Relationship problems Thoughts of harming self Concern about someone else Roommate problems Thoughts of harming others Depression/low mood Self-esteem

Please list below the people in your family and any other significant individuals in your life

Name

Relationship to you

Age

Occupation

Counseling Services