Issues of Concern and Personal Resources
To help your counselor meet your counseling needs, please check relevant boxes.
Relationships Somewhat A Lot
Family ( ) ( )
Friends ( ) ( )
Roommate ( ) ( )
Boyfriend/Girlfriend ( ) ( )
Other __________ ( ) ( )
Adjustment/Change
Beginning College ( ) ( )
Returning to College ( ) ( )
Thinking of leaving college ( ) ( )
Preparing to graduate ( ) ( )
Loss, Injury, Death ( ) ( )
Trauma/Abuse
Sexual Assault ( ) ( )
Physical Assault ( ) ( )
Emotional Abuse ( ) ( )
Academics
Confusion ( ) ( )
Extensions/Incompletes ( ) ( )
Learning difficulties/disability ( ) ( )
Attention Deficit Disorder ( ) ( )
Other
Body Image/ Eating Issues ( ) ( )
Self-Esteem ( ) ( )
Depression
Situational ( ) ( )
Long Term ( ) ( )
Suicidal Thoughts ( ) ( )
Disturbing Thoughts ( ) ( )
Anxiety
Periodic discomfort ( ) ( )
Panic attacks ( ) ( )
Obsessive-Compulsive ( ) ( )
Abuse, Dependence & Addictions
Substances ( ) ( )
Sex ( ) ( )
Internet ( ) ( )
Religion/Spirituality ( ) ( )
Sexuality
Questions ( ) ( )
Orientation ( ) ( )
Function ( ) ( )
Name ______________________________________
Date ______________________________________
Class _____________ Tel. Ext. ______________
Diversity Somewhat A Lot
Experiences of difference ( ) ( )
Race ( ) ( )
Religion ( ) ( )
Geography ( ) ( )
Medical ( ) ( )
Current Medications
and/or Over the Counters_____________________________
Harassment ( ) ( )
Finances ( ) ( )
Other Issues
________________ ( ) ( )
________________ ( ) ( )
Supportive Personal Resources
Friends ( ) ( )
Family ( ) ( )
Self ( ) ( )
Religion ( ) ( )
Accomplishments ( ) ( )
Travel ( ) ( )
Fitness ( ) ( )
Arts ( ) ( )
Humor ( ) ( )
Other ( ) ( )
Family
Please note family members living (L) or deceased (D)
Mother ( ) Father ( )
Stepmother ( ) Stepfather ( )
Grandmother ( ) Grandfather ( )
Sister ( ) Brother ( )
Step-sister ( ) Step-brother ( )
Parents: Married ( ) Divorced ( ) Remarried ( )
Ethnic Origin
Check all that apply
( ) African American ( ) Asian/Pacific American
( ) European American ( ) Hispanic/Latino American
( ) Native American
( ) International Student _____________________________
( ) Other _________________________________________
First time speaking with a mental health professional. ( ) Yes ( ) No
If a group is forming related to your concerns, might you be interested in participating? ( ) Yes ( ) No
May we e-mail you our Client Feedback form? ( ) Yes ( ) No
May we communicate with you via e-mail? ( ) Yes ( ) No
Have you ever visited our website? ( ) Yes ( ) No
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In counseling are you primarily needing (Check One)
1. Copoing Skills and strategies ( )
2. Self-exploration and self-understanding ( )
3. Both ( )