CWU: Student Counseling Clinic Name (Please Print): ______

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CWU: Student Counseling Clinic Name (Please Print): ______

SUPPLEMENTARY CLIENT INTAKE FORM Date: ______

In your own words, what are you struggling with that prompts you to seek counseling right now?
Describe special interests, hobbies, or activities that you enjoy and that you have been avoiding as a result of what you have been struggling with:
What are the three things that you value the most in your life right now?
What change(s) would have to happen in order for you to improve your life?
1. What is your sexual orientation?  Heterosexual  Lesbian  Gay  Bisexual  Questioning
2. How important are religious/spiritual matters to you?  Not Very  A Little  Moderate  A Lot

3. Are you currently affiliated with a religious/spiritual group?

Yes

No

4. Are there any special, unusual, or traumatic circumstances that affected you growing up (e.g., abuse, neglect, violence, family violence, and/or assault)? /

Yes

No

5. Are you currently involved in any legal actions (either as a defendant or plaintiff)?

Yes

No

6. Do you have any past history of criminal charges or civil actions?

Yes

7. How would you characterize your current health?  Excellent  Good  Fair  Poor
8. Do you have any disabilities we should know about, or that might impact counseling? /

Yes

9. Are you currently being evaluated or treated for any physical complaints, pains, or illnesses?

Yes

10. Do you have any history of out-of-the-ordinary illnesses? /

Yes

11. Do you have any health-related concerns that you are not currently being treated for?

Yes

12. Please check whether you’ve experienced any of the following in the past couple of weeks:
Sleep difficulties Lack of interest in activities Feelings of guilt/remorse  Poor energy
Appetite changes  Difficulty concentrating  Reduced/increased activity level  Weight gain/Loss

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Please list all prescribed medications and any over-the-counter medications or supplements that you take.

Medication / Dose / Prescribed by
Over-the Counter Medication or Supplement / How often is it used?
13. Have you ever been in trouble as a result of drinking or substance use (e.g., minor in possession, DUI, DWI, drunk and disorderly, etc.)? /

Yes

14. Do you think your substance use is interfering with your school performance, social relationships, job performance, or other responsibilities? /

Yes

15. Even if you aren’t concerned, has anyone else ever thought that you should stop or reduce your use of substances?

Yes

17. Have you ever seen a mental health provider for services (e.g., school counselor, social worker, mental health counselor, psychologist, or psychiatrist)? /

Yes

18. Is there anyone in your immediate family with a history of psychiatric illnesses (e.g., depression, anxiety, substance abuse, schizophrenia, bipolar disorder, etc.)? /

Yes

19. Do you currently have, or in the past couple of weeks have you had, thoughts or feelings about ending your life? /

Yes

20. Have you felt hopeless lately, like things wouldn’t improve or get better?

Yes

21. Have you ever attempted suicide?

Yes

22. Has there ever been a time when people thought you were either too thin or losing too much weight?

Yes

23. Have you ever felt out of control and gone on eating binges during which you ate an abnormally large amount of food?

Yes

24. Has there ever been a time, lasting at least a few days, during which you felt hyper, charged up with energy, and you thought this was different from your usual self?

Yes

25. Before attending college, were you ever identified as having a learning disability or as having an attention deficit (ADHD)? /

Yes

26. Are you currently employed, even part-time? /

Yes

27. Have you ever served in the military service, or consider yourself a veteran? /

Yes

S:\Health_Center\Counseling Clinic Shared\Front Office Forms Docs\Supplementary Intake Form 11-13-2013.docx