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Name
Date of Birth
Phone
Email
In case of emergency
Current year and program
Ethnicity
Relationship status
Current living situation
Please describe your current concerns, challenges or symptoms?
Who referred you to counseling?
Have you had previous counseling (If so, please list when and with whom)?
Please list any current and or past medication within the past two years (please include dosage, if and when possible)
Please list family members with any current or previous emotional or physical health concerns/challenges
Current strengths/healthy coping
Moods/Behaviors
anxious/worried
depressed/unhappy
eating disorder/body image concerns
hyperactive/inattentive
shy/withdrawn
low self-esteem
aggressive behaviors
stealing/lying
other
Other moods/behviors
School Concerns
homework challenges
low test/assignment grades
poor classroom performance
sleeping in class/always tired
sudden change in grades
frequently tardy or absent
new student
other
Other School Concerns
Relationships
bullying
difficulty making friends
poor social skills
problems w/ friends
boy/girl friend issues
other
Other Relationships
Home Concerns
fighting w/ family members
illness/death in the family
parents divorced/separated
physical/sexual abuse
drug/substance abuse
parent request
other
Other Home Concerns
