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Student Counseling Center

Intake Form

Thank you for taking the time to complete this form. The information provided will be used by the JBU Student Counseling Center to serve you. All responses will be kept strictly confidential.

Today's Date:
Student ID#:
Referral source:
 
 

I. General Information
 
Full Name:
DOB: Age: Sex:
Address:
City: State: Zip:
Marital Status:    
Classification:    
International/MK/Walton
Major:    
Current Enrollment Hours: GPA:  
Phone #: E-mail:
  (We will contact you via e-mail to confirm your appointment time)
Are you currently working?    
If yes, where and how many hours per week do you work?
Place: Hrs/wk: Work Phone #:
What is your church/denominational background?
Have you been a previous client at the JBU Counseling Center?  
If yes, would you like to continue working with your previous therapist?
If yes, who was your previous therapist
What days and times are you available to be seen by a therapist?
Monday: 9am 10am 11am 12pm 1pm 2pm 3pm 4pm
Tuesday: 9am 10am 11am 12pm 1pm 2pm 3pm 4pm
Wednesday: 9am 10am 11am 12pm 1pm 2pm 3pm 4pm
Thursday: 9am 10am 11am 12pm 1pm 2pm 3pm 4pm
Friday: 9am 10am 11am 12pm 1pm      
                 
                 

II. HEALTH
 
1. Briefly describe your reasons for seeking help, how long it has been a concern, and what you hope to
accomplish through therapy.
 
For the next set of questions, use the following scale:  
No, definitely not________________________Yes, Definitely  
1__________2___________3___________4___________5  
My reasons for seeking help impair my academic performance.
My reasons for seeking help impair my work performance.
My reasons for seeking help impair my relationships with others.
My reasons for seeking help impair my relationship with God.
My reasons for seeking help impair my thoughts and feelings of myself.
 
2. Describe previous counseling or treatment you received for mental health or family/social problems.
Please specify if you have a history of physical/sexual/emotional abuse. (Please list dates of treatment and
who provided the treatment.)
 
If you are currently seeing a therapist, have you terminated therapy?
 
3. Please comment on any member of your family who abuses substances, and/or has a mental health problem (e.g., eating disorder, depression), and/or has been physically, sexually, or verbally abused. Also state the treatment they have received.
 
4. Name of your physician:
Date of last medical exam:
List medications and dosages currently taking:
Medication: Dosage:
Medication: Dosage:
Medication: Dosage:
Medication: Dosage:
 
List important past or present illnesses, injuries, surgeries, and/or hospitalizations:
 
 

III. FAMILY INFORMATION
 
Is either of your parents deceased?
If yes, what was their approximate age at death and your age when the death(s) occurred?
Parent's Age: Your Age:
Parent’s Marital Status:
If divorced, year of divorce: Your Age:
Parents/Step-parents  
Mothers Name: Age:
Education:
Occupation:
Father's Name: Age:
Education:
Occupation:
Siblings:
Name: Age:
Name: Age:
Name: Age:
 
If reared by someone other than parents/step-parents, who were they and how old were you when you lived with them?
Guardian Name: Age:
Guardian Name:  
 
 

IV. ADDITIONAL INFORMATION
 
How would you describe your physical health?
 
How frequently do you exercise?
How many hours of sleep per night have you averaged in the last week?
What three words would you use to describe:
Yourself:
Your Father:
Your Mother:
God:
Which of the following do you attend or are a member of? (Check all that apply.)









 
Please respond to each of the following symptoms by indicating in the boxes provided how much of a
problem they have been in the last two weeks using the following scale:
1-Serious Problem
2-Moderate Problem
3-Minor Problem
4-Not a problem
Depressed Mood Thoughts of Death/Suicide Compulsive Behavior
Loss of Interest (in things you once enjoyed) Anger Panic Attacks
Anxious/Nervous Increased Appetite Racing Thoughts
Problems w/Sleep Decreased Appetite Poor Judgment
Excessive Feelings of Guilt Chest Discomfort Sweats/Chills
Excessive Worry Nightmares Difficulty Breathing
Fatigue/Loss of energy Irritability Flashbacks
Significant Weight Gain Significant Weight Loss Social Withdrawal
Difficulty w/ Concentration Feelings of Hopelessness Impulsive Behavior
     
Please check all of the following that describe previous or current behavior:









Comments:
 
 

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