Intake Information Form This field is hidden when viewing the formDate MM slash DD slash YYYY Are you completing this form for yourself or on behalf of someone else?* For myself On behalf of someone else Your Name* First Last Student/Patient Name* First Last Date of Birth* MM slash DD slash YYYY Age*Sex* Male Female Other Do you live on-campus?* Yes No Residence Hall*Room Number*Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Can we leave a message?* Yes No Email* Can we email?* Yes No MajorMinorAre you a full-time or part-time student? Full-time Part-time Marital Status* Single Divorced Widowed Married Separated Ethnicity* Asian African American Bi-Racial Caucasian Hispanic Other Are you a veteran?* Yes No Student Classification* Freshman Sophomore Junior Senior Graduate Other Who referred you? Self RA Advisor Professor Family Friend Other Medical HistoryPresenting Problem* Depression Anxiety Suicidal thoughts Stress Conflict with others Decision making Other Other presenting problem*Have you ever taken medications?* Yes No Are you currently taking any medications?* Yes No What medication(s) and dose?*Have you ever received counseling?* Yes No When and where have you received counseling?Do you have a previous diagnosis?* Yes No What diagnosis?Any medical conditions?Emergency ContactsPlease list emergency contacts belowNamePhoneRelationship Limits of Confidentiality Counseling services provided by the Counseling Center at SAU are confidential. No information can be shared with another party without the written consent of the student/client. It is the policy of this office not to release any information about a student/client without a signed release of information. There are exceptions to this as follows: Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the counselor is required to warn the intended victim and report this information to the legal authorities. In cases in which the client discloses or implies a plan for suicide, the counselor is required to notify legal authorities and make reasonable attempts to notify the family of the client. Abuse of Children and Vulnerable Adults If a student/client reports or implies child abuse or abuse of a vulnerable adult, the counselor is required to report this information to the appropriate social service and/or legal authorities. Court Orders Counselors are required to release records of students/clients when a court order has been issued for such records. Other At the Center we utilize student workers. They have received confidentiality training. The Center also utilizes interns from the Counseling Department. They are training to be professional therapists and have received confidentiality training. Students have the right to refuse intern participation. All of our counselors are trained in Technology Assisted therapy.In the event in which someone from this office must contact a student/client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please identify your preferred mode of contact?* Phone Email None Would you like a copy of Limits of Confidentiality?* Yes No Consent* By submitting this form, I agree to the above limits of confidentiality and understand their meanings and ramifications. Δ
