Counseling Service Personal Information Form. Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices?
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1 Date: Counseling Service Personal Information Form Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices? Yes No Phone number: May the Counseling Service leave you a voic message? Yes No Can this phone number be updated for all LC Health and Wellness offices? Yes No **: May we contact you by for scheduling purposes ONLY**? Yes No ** is not a secure form of communication Who referred you to the Counseling Service? Self Family Friend LC Website Student Health Service Student Support Services Health Promotions Campus Living Career Center International Student Services Financial Aid Dean of Students Ombuds Office Faculty (please specify) Advisor (please specify) Other (Please specify) If asked to specify, please do so here: Do you have the school-sponsored insurance plan? Y/N If not, who is your carrier? In case of serious medical emergency, who should be notified? Phone Relationship What is your academic status? Part-time Full-time What is your class standing? First-year Sophomore Junior Senior Graduate student Law Student Non-degree Current Major: Advisor s name: GPA last term: Cumulative GPA: For how many credits are you currently enrolled? Did you transfer from another campus/institution to this school? Yes No Are you the first generation in your family to attend college? Yes No Are you an international student? Yes No If yes, what is your country of origin? What is your current gender? Female Male Trans-FTM Trans-MTF Gender fluid Genderqueer Non-binary Questioning/unsure Prefer not to answer Other (please elaborate) If you would like to, please further describe your gender identity: Preferred pronouns: She/her/hers He/him/his They/them/their Prefer not to answer Other (please elaborate) If you have an alternate preference, please specify:
2 Please describe your racial, cultural, ethnic, or regional identity: What is your sexual orientation? Lesbian/Gay Queer Heterosexual/Straight Bisexual Pansexual Questioning Other (please elaborate) Prefer not to answer If you would like to, please further describe your sexual orientation: What is your relationship status: Single Dating Partnered Married or Registered domestic partnership Separated Divorced Widowed Other (please elaborate) If you would like to, please further describe your relationship status: Do you have (or suspect you have) a disability (e.g., physical, sensory, learning, ADHD, etc.) that you d like us to know about? Yes, I have a disability and I am registered with Student Support Services Yes, I have a disability, but I am NOT registered with Student Support Services Yes, I suspect I have a disability, but I have not been diagnosed No If you selected, Yes for the previous question, please indicate which category of disability (check all that apply): Attention Deficit/Hyperactivity Disorders Deaf or Hard of Hearing Learning Disorders Mobility Impairment Neurological Disorders Physical/health related Disorders Psychological disorders/condition Visual impairments Other (please specify) Prior to today, have you attended counseling for mental health concerns: Prior to Starting college After starting college Both Have you taken a prescribed medication for mental health concerns: Prior to Starting college After starting college Both Please list ALL current prescription medications and dosages:
3 How often do you have a drink containing alcohol? (One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.) Monthly or less 2-4 times per month 2-3 times per week 4 or more times per week How many drinks containing alcohol do you have on a typical day when you are drinking? None One or Two Three or Four Five or Six Seven-Nine Ten or More How often do you use marijuana (weed, pot, hash, hash oil)? Monthly or less 2-4 times per month 2-3 times per week 4 or more times per week How many caffeinated beverages (including coffee/soda) do you have on an average day? Based on an average month, please indicate your frequency of use: Cocaine (crack, rock, freebase) Opiates (heroin, methadone, pain pills) Amphetamines (diet pills, speed, meth, crank) ADHD medications- unprescribed (Ritalin, Adderall, etc.) Other psychoactive drugs (K, mushrooms, molly, etc.) Nicotine (cigarettes/cigars, smokeless tobacco, vape, etc.) Over-the-counter medication (non-prescription) Daily Weekly Monthly Rarely Please indicate which of the following have resulted from your use of alcohol/drugs in the last year: Injury to yourself Injury to someone else DUI/DWI violation Blackouts College Disciplinary Action Arguments/conflicts with a friend Other legal problems Academic problems (e.g. missed classes, problems studying) Please indicate your goal(s) for seeing a counselor: How much are your counseling concerns hurting your schoolwork? (Circle a number) Not at all Very much
4 Please indicate how many times and the last time you had each of the following experiences: Purposely injured yourself without suicidal intent (e.g. cutting, hitting, burning, etc.): 2-10 times Within the last month times Within the last year More than 20 times Within the last 1-5 years Been hospitalized for mental health concerns: Seriously considered attempting suicide: Made a suicide attempt:
5 Student Concerns Rating Scale: The following items represent some common concerns of college students. How much has each problem been distressing or bothering you within the last month? (Circle your answer for each item.) 0= Not at all 1= A little bit 2= Moderately 3=Quite a bit 4= Extremely 1. Problems being successful academically Concern about staying in school Feeling lonely, isolated, or not having close friends Difficulty getting along with others Problems with parenting your children Problems with a romantic, dating or sexual relationship Family problems Financial problems Eating, appetite or weight issues Concerns about your physical appearance Problems paying attention or concentrating Feeling anxious, nervous, fearful, worried or panic Self-esteem Mood swings (highs and lows) Feeling sad, depressed, discouraged or hopeless Being self-critical or feeling guilty Trouble sleeping or sleeping too much Self-injurious behavior (e.g., cutting, burning, bruising) Thoughts of suicide Intentions of suicide Feeling irritable or angry Thoughts of wanting to hurt someone else Hearing voices or seeing things that others don t see Internet use or computer gaming Use of alcohol, marijuana or other drugs Other addiction (e.g., gambling, nicotine, pornography, sex, etc.) Physical health problems Difficulties with a disability Experiencing prejudice, racism, or discrimination Concerns about your major or career choice Concerns associated with a sexually transmitted disease Problems with your living situation Being a victim of unwanted sexual activity, sexual abuse or rape Being a victim of violence Dealing with a loss from death, separation, divorce or moving Adjusting to a new culture Issues related to pregnancy Concerns about your sexuality Other (specify):
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