Student Counseling Center

Student Counseling Center

Termination Summary

Name ID#

PART I: THERAPEUTIC ISSUES

Check all issues that apply. Indicate "PRIMARY" Personal (e.g., emotional,relationship,family) Yes No

for primary issues, with a maximum of two Career (e.g.,major,career choice, planning future) Yes No

"PRIMARY" issues. Educational (e.g.,studying,procrast,test anx.,req.) Yes No

Academic (motivationprogressmotivation & progress) [PRIMARY] MMPI-II interpretation only [PRIMARY]

Adjusting to University [PRIMARY] Major/Career Exploration [PRIMARY]

Anger control [PRIMARY] Mood disorder (depressionbipolar) [PRIMARY]

Anxiety (performancedisorderperformance & disorder) [PRIMARY] Pregnancy/abortion [PRIMARY]

Assault (physical, not sexual) [PRIMARY] Relationship problems (romanticmaritalpeersfaculty) [PRIMARY]

Childhood Abuse (sexualphysical) [PRIMARY] Self concept/self-esteem [PRIMARY]

Death or other extreme loss [PRIMARY] Sexual (dysfunctionidentity) [PRIMARY]

Substance Abuse (drugsalcoholdrugs & alcohol) [PRIMARY] Sexual assault (strangeracquaintancerelative) [PRIMARY]

Eating concerns (anorexiabulimiaover eatingother) [PRIMARY] Sexual orientation concerns [PRIMARY]

Family [PRIMARY] Stress Management [PRIMARY]

Suicidal (ideationthreatattemptcompletion) [PRIMARY] Thought disorder/psychosis [PRIMARY]

Other: [PRIMARY]

PART II: INTERVENTIONS Number of

Staff Providing Service Type of Service Provided Sessions

______Larry Long, Ph.D.Janet Trepka, M.S.Christopher Stanley-Stevens, M.Div. ______Primary InterviewCont. Interview - Indiv.Cont. Interview - couplesCont. Inverveiw - familyTest InterpretationBiofeed/Relax. TrainingConsultationPresentation can no show

______Larry Long, Ph.D.Janet Trepka, M.S.Christopher Stanley-Stevens, M.Div. ______Primary InterviewCont. Interview - Indiv.Cont. Interview - couplesCont. Inverveiw - familyTest InterpretationBiofeed/Relax. TrainingConsultationPresentation can no show

______Larry Long, Ph.D.Janet Trepka, M.S.Christopher Stanley-Stevens, M.Div. ______Primary InterviewCont. Interview - Indiv.Cont. Interview - couplesCont. Inverveiw - familyTest InterpretationBiofeed/Relax. TrainingConsultationPresentation can no show

______Larry Long, Ph.D.Janet Trepka, M.S.Christopher Stanley-Stevens, M.Div. ______Primary InterviewCont. Interview - Indiv.Cont. Interview - couplesCont. Inverveiw - familyTest InterpretationBiofeed/Relax. TrainingConsultationPresentation can no show

Date first contact: Date last contact:

DIAGNOSIS (if any): Cooperative?

PART III: REASON FOR TERMINATION

problems resolved end of semester

premature termination referred for outpatient counseling

assessment only referred for hospitalization

other:

PART IV: TREATEMENT SUMMARY, PROGRESS, AND RECOMMENDATION

Termination Summary prepared by:______Date: 10/23/98