UWM Counseling and Consultation Services Intake Form
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- Abner Booker
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1 UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes to tell us about yourself. Thank you for your assistance! First name Middle name Last name Name you preferred to be called Date of Birth Preferred Mailing Address Street City Zip Preferred Phone Emergency Contact Name Relationship May we leave a message? Yes No Contact Phone Who referred you to the Counseling Center? Self Family Faculty/staff Friends University Housing Health Center staff Dean of Students Office Other: Do you have health insurance? Yes No Unsure Academic Major On Probation? Yes No Are you the first in your family to attend college? Yes No Current Employment? Yes No If so, type of work Hours per week List the current prescription medications, over the counter medications and supplements you are taking: FAMILY COMPOSITION: Age Occupation Siblings # Ages Children # Ages Spouse/Partner Female Daughters Mother Male Sons Father Is there a history of alcoholism or substance abuse in your family? Yes No Uncertain Is there a history of mental health concerns in your family? Yes No Uncertain 1
2 I am concerned about the following (check all that apply): Problems related to school and grades Urge to injure / harm someone else Choice of major / career Sexual orientation Attention / concentration Gender identity Procrastination / motivation Cultural adjustment Stress / stress management Bullying / harassment Low self-esteem / confidence Prejudice / discrimination Anxiety / fears / worries (other than Marital / couple / family concerns academic) Shyness / social discomfort Friends / roommates / dating concerns Depression / sadness / mood swings Sexual assault / dating violence / stalking / harassment Grief / loss Sleep difficulties Anger / irritability Eating behavior / weight problems / eating disorders / body image Seeing / hearing things others don t Physical symptoms / health (headaches, stomachaches, pain) Childhood abuse (physical, emotional, sexual) Alcohol / drug use Suicidal thoughts / urges Other (please specify) Self-injury (cutting, hitting, burning) What is your main reason for visiting the Counseling Center? Please indicate the degree to which you agree/disagree with the following statements: I am struggling with my academics. I am thinking of leaving school My academic motivation and/or attendance are suffering. I am having a hard time focusing on my academics. Please indicate if and when you have had the following experiences: Attended counseling for mental health concerns Prior to college After starting college Both Taken a prescription medication for mental health concerns Prior to college After starting college Both Please indicate how many times and time you had each of the following experiences: Been hospitalized for mental health concerns 1 time 2-3 times 4-5 times times Been hospitalized for mental health concerns (last time) 2 the Felt the need to reduce your alcohol or drug use 1 time 2-3 times 4-5 times times 2
3 Felt the need to reduce your alcohol or drug use (last time) 2 the Others have expressed concern about your alcohol or drug use 1 time 2-3 times 4-5 times times Others have expressed concern about your alcohol or drug use (last time) 2 the Received treatment for alcohol or drug use 1 time 2-3 times 4-5 times times Received treatment for alcohol or drug use (last time) 2 Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, etc.) Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, etc.) (last time) the 1 time 2-3 times 4-5 times times 2 the Seriously considered attempting suicide 1 time 2-3 times 4-5 times times Seriously considered attempting suicide (last time) 2 the Made a suicide attempt 1 time 2-3 times 4-5 times times Made a suicide attempt (last time) 2 the Considered causing serious physical injury to another person 1 time 2-3 times 4-5 times times Considered causing serious physical injury to another person (last time) 2 the Intentionally caused serious physical injury to another 1 time 2-3 times 4-5 times times Intentionally caused serious physical injury to another (last time) Someone had sexual contact with you without your consent (e.g., you were afraid to stop what was happening, passed out, drugged, drunk, incapacitated, asleep, threatened or physically forced) Someone had sexual contact with you without your consent (e.g., you were afraid to stop what was happening, passed out, drugged, drunk, incapacitated, asleep, threatened or physically forced) (last time) Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure) Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure) (last time) 2 the 1 time 2-3 times 4-5 times times 2 the 1 time 2-3 times 4-5 times times 2 the 3
4 Think back over two. How many times have you smoked marijuana? ne Once Twice 3 to 5 times 6 to 9 times 10 or more times Are you registered, with the office for disability services on this campus, as having a documented and diagnosed disability? If you selected, Yes for the previous question, please indicate which category of disability you are registered for (check all that applies): Attention Deficit/Hyperactivity Disorders Deaf or Hard of Hearing Learning Disorders Mobility Impairments Neurological Disorders Physical/health related Disorders Psychological Disorder/Condition Visual Impairments Other (please specify) Age What is your gender identity? Woman Man Transgender Self-identify (please specify) Do you consider yourself to be: Heterosexual Lesbian Gay Bisexual Questioning Self-identify (please specify) What is your race / ethnicity? African American / Black American Indian or Alaskan Native Asian American / Asian Hispanic / Latino/a Native Hawaiian or Pacific Islander Multi-racial White Self-identify (please specify) What is your country of origin? Are you an international student? Relationship status: Single Serious dating or committed relationship Civil union, domestic partnership, or equivalent Married Separated Divorced Widowed Religious or spiritual preference: Agnostic Atheist Buddhist Catholic Christian Hindu Jewish Muslim preference Self-identify (please specify) Current academic status: Freshman / First-year Sophomore Junior Senior Graduate / professional degree student Faculty or staff Other (please specify) What kind of housing do you currently have? On-campus residence hall/apartment On/off campus co-operative house Other (please specify) On/off campus fraternity/sorority house Off-campus apartment/house 4
5 With whom do you live? (check all that apply) Alone Spouse, partner, or significant other Roommate(s) Children Parent(s) or guardian(s) Family other Other (please specify) What is your current GPA? Have you ever served in any branch of the US military (active duty, veteran, National Guard, or reserves)? Did your military experiences include any traumatic or highly stressful experiences which continue to bother you? What is the average number of hours you work per week during the school year (paid employment only)? How would you describe your financial situation right now: Always stressful Often stressful Sometimes stressful Rarely stressful stressful Student ID: The Counseling Center participates in a University of Wisconsin (UW) System study designed to evaluate the impact of counseling/mental health services on student well-being and academic success. Confidential data provided by those who use our services (and are over 18 years old) are contributed to a database managed by researchers at UW Oshkosh. Data are stripped of all personally identifying information (student ID) and then combined with de-identified data from other UW schools. No attempts are made to trace your responses back to you. With your permission, we would like to contribute confidential data from the questionnaire you completed today. Your participation is voluntary and will not affect the services you receive. If you have questions or concerns, you may contact the Counseling director, Paul Dupont, Ph.D. at or [email protected] or the researcher: Erin Winterrowd, Ph.D. Department of Psychology University of Wisconsin Oshkosh Oshkosh, WI (920) [email protected] If you have any complaints about your treatment as a participant in this study, please contact the Chair, below. Although the chairperson may ask for your name, all complaints will be kept in confidence. Chair, Institutional Review Board for Protection of Human Participants c/o Grants Office UW Oshkosh Will you allow your confidential responses to be contributed? Revised 8/20/14 5
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