Date

Date___________________

STUDENT COUNSELING CENTER

CLIENT DATA SHEET

The following forms will take a few minutes to complete and will provide information which will help your therapist better understand your concerns.

CONFIDENTIALITY

This information is CONFIDENTIAL. Ordinarily, no client information will be released to ANY source unless the client gives written permission. However, if an urgent situation occurs in which permission is not obtainable, your therapist reserves the right to discuss pertinent information with other professionals such as psychologists and physicians who would be involved in helping you. If you would like further information or have any questions about the Center= s policy on Confidentiality, your therapist will be happy to discuss it with you.

Name_________________________________________________________ Local Phone ( )______________________________

Local Address (street, city, state, zip)____________________________________________________________________________________

Campus mailbox or zip___________________________________________________ email ______________________________________

College/Program _____________________________________________________________________

Yr. in program___________________

Previous college education (List college(s) and degrees/certificates earned)

_________________________________________________________________________________________________________________

Hometown________________________________________________________ High School_______________________________________

Military service (branch, dates of service)_________________________________________________________________________________

Currently employed? No______ Yes______ Where employed?________________________________________________________________

Sex________ Age________ Marital Status: single______ married______ divorced______ separated______

Date of marriage: _________________ widowed_______ unmarried, living w/partner________

Name of spouse/significant other:_________________________________________ Occupation:____________________________________

List children (name, age, gender):______________________________________________________________________________________

Name(s) of roommate(s):_____________________________________________________________________________________________

Parents: Name Age Occupation

Father______________________________________________ ___________ __________________________________________________

Mother_____________________________________________ ____________ __________________________________________________

Parent's marital status: Living together ______ Divorced/separated ______

Father deceased______ Mother deceased ______ Both deceased ______

Brothers/Sisters (name, age, occupation) ________________________________________________________________________________

_________________________________________________________________________________________________________________

EMERGENCY CONTACT:

Name: ______________________________________________________________ Phone: _______________________________________

Address:__________________________________________________________________________________________________________

Relationship to you:__________________________________________________________________________________________________

COUNSELING HISTORY
1. Please list any previous professional counseling you have had, starting with the most recent:
  
  Name of Therapist/Agency, City Dates fr-to Reason
  
  _______________________________________________ ________________ ____________________________________
  
  _______________________________________________ ________________ ____________________________________
  
  _______________________________________________ ________________ ____________________________________
2. Please list any previous psychiatric medical treatment you have had, starting with the most recent:
  
  OUTPATIENT
  
  Name of Doctor/Agency Dates fr-to Reason
  
  _______________________________________________ ________________ ____________________________________
  
  _______________________________________________ ________________ ____________________________________
  
  _______________________________________________ ________________ ____________________________________
  
  INPATIENT HOSPITALIZATION
  
  _______________________________________________ ________________ ____________________________________
  
  MEDICATIONS PRESCRIBED (anti-depressant, anti-anxiety, etc.)
  
  ____________________________________________________________________________________________________
3. Have you been treated for alcohol/substance abuse? (When, where?)
____________________________________________________________________________________________________

MEDICAL HISTORY
1. Describe any recent or current medical problems. How long?
  
  ____________________________________________________________________________________________________
  
  ____________________________________________________________________________________________________
2. List any medications you are taking now.
         ____________________________________________________________________________________________________

         ____________________________________________________________________________________________________

         ____________________________________________________________________________________________________
PRESENTING PROBLEM AND REFERRAL SOURCE
1. Briefly, what is the problem that brings you to the Counseling Center today?
  
  ____________________________________________________________________________________________________
  
  ____________________________________________________________________________________________________
  
  ____________________________________________________________________________________________________
2. Who suggested the Counseling Center to you?
  Friend______ Faculty ______ Dean ______ Student Health ______ Parents ______
  Self ______ Brochure ______ Class Presentation ______ Web site ______ Other _________________________________

How much have you experienced or worried about:	Not at all Moderately Frequently
1. Feeling anxious, tense or nervous	1	2	3	4	5
2. Feeling depressed, dejected, sad	1	2	3	4	5
3. Feeling timid, shy, or ill at ease with others	1	2	3	4	5
4. Indecisiveness, unclear goals	1	2	3	4	5
5. Lack of interest, motivation	1	2	3	4	5
6. Inability to concentrate	1	2	3	4	5
7. Academic concerns (grades, test anxiety, etc.)	1	2	3	4	5
8. Troubling thoughts or dreams	1	2	3	4	5
9. Self-critical thinking.	1	2	3	4	5
10. Chronic muscle tension	1	2	3	4	5
11. Suicidal thoughts	1	2	3	4	5
12. Headaches or visual disturbances	1	2	3	4	5
13. Loss of appetite	1	2	3	4	5
14. Upset stomach/GI tract	1	2	3	4	5
15. Compulsive eating	1	2	3	4	5
16. Excessive alcohol or drug use	1	2	3	4	5
17. Dizziness or racing heart	1	2	3	4	5
18. Unreasonable fears	1	2	3	4	5
19. Irritable or angry feelings	1	2	3	4	5
20. Inability to sleep well	1	2	3	4	5
21. Problems with friends	1	2	3	4	5
22. Family problems	1	2	3	4	5
23. Work-related problems	1	2	3	4	5
24. Couples communication problems	1	2	3	4	5
25. Sexual problems	1	2	3	4	5