WELLNESS CENTER COUNSELING INTAKE FORM Today’s date: Student ID :Gender: Name: Date of birth: Ethnicity:Education Level: Major: Campus address: City: State: Zip: Home address:City:State:Zip: Phone (h): (email): (cell): Emergency Contact Person: Phone: Relationship to you: Referred by: Do you work:Where:Position: Counseling History Have you had previous counseling:Dates: Name of counselor: Explain why: Reason for this appointment request today: List any concerns you have: Are you currently taking any medications:What:Why: Have you ever thought about, or attempted suicide: Has anyone in your family, or friends committed, or attempted suicide: If yes who: What are your positives: Please Complete if You Are Requesting Accommodations for Disability Have you read The American Disability Act and student checklist requirements located in the University Catalog, Student Handbook, or on the Kettering website: What type of disability do you have: Do you have current documentation to prove
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