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:_________________________________________________________