Boynton Mental Health Clinic, 4Th Floor, 410 Church Street SE

COMMON INTAKE FORM

Boynton Mental Health Clinic, 4th Floor, 410 Church Street SE

Student Counseling Services, 340 Appleby Hall, 128 Pleasant Street SE

Today’s Date: / First Name: / Middle Name: / Last Name:
Date of Birth: / Age: / Student I.D.: / Preferred Name: / Preferred Pronouns:
Cell Phone: / OK to call cell phone? / Home Phone: / OK to call home phone?
☐ / ☐ /
Email: ☐ OK to Email?
Local Address: (OK to contact you at home?) ☐ / Permanent Address:
Street: / Street:
City: / City:
State/ZIP: / State/ZIP:
Emergency Contact Person:
Relationship to You:
Telephone:

What kind of help are you seeking? Select all that apply:

☐ Individual therapy/counseling ☐ Medication management (BHS) ☐ Group counseling ☐ Couples counseling (BHS) ☐ Substance use counseling (BHS) ☐Medical social work/Case management ☐ Academic counseling (SCS) ☐ Career counseling (SCS)
Other:

What is your primary reason for seeking help?

Are you currently experiencing a crisis? / ☐ / Yes / ☐ / No
Describe the nature of the crisis:

What other significant concerns do you have?

What convinced you to get help now?

Are you requesting to have a form or letter completed on your behalf? / ☐ / Yes / ☐ / No

If yes, please describe:

Page 2

COMMON INTAKE FORM

Boynton Mental Health Clinic, 4th Floor, 410 Church Street SE

Student Counseling Services, 340 Appleby Hall, 128 Pleasant Street SE

How satisfied are you with your academic progress? / ☐ Very satisfied ☐ Satisfied ☐ Neutral ☐ Dissatisfied ☐ Very dissatisfied

What barriers, if any, are impeding your academic progress so far?

What do you like best about college and college life?

What do you like least about college and college life?

What are your long term education and vocational goals?

Other important long-term plans and goals?

How sure are you about these plans? / ☐ Very Certain ☐ Certain ☐ Uncertain ☐ Very uncertain

Please list any previous or current mental health therapy and any previous hospitalizations:

Provider/Clinic / Condition/Issue / Date(s)

Do you have any health problems?

Please list any current medications (psychiatric, medical, and over-the-counter):

Medication / Dose / Benefits/Side Effects

Please describe your primary parental figures:

Parent #1 / Parent #2
How related to you
Education
Occupation
Number of siblings / Full: / Half: / Step:

Page 3

COMMON INTAKE FORM

Boynton Mental Health Clinic, 4th Floor, 410 Church Street SE

Student Counseling Services, 340 Appleby Hall, 128 Pleasant Street SE

Gender: Please check the appropriate box or fill in below:
☐Male ☐Female ☐ Transgender ☐Fluid
☐My description (please fill in):
☐ Prefer Not to Answer / Sexual Orientation: Please check the appropriate box or fill in below:
☐Asexual ☐Bisexual ☐ Gay ☐Hetero/straight
☐Questioning ☐ My description (please fill in):
☐ Prefer Not to Answer
Relationship Status: ☐Single ☐ Dating ☐ Partnered ☐ Married ☐ Separated ☐ Divorced ☐ Other:

Undergrad Student: ☐Fresh ☐ Soph ☐ Junior ☐Senior ☐ PSEO ☐ Other

College: / Major: / Minor:
☐ / Grad School Masters / Program:
☐ / Grad School Ph.D. / Program:
☐ / Professional School / Program:
Current Credit Load: / Anticipated Graduation Date:
Military Service Status: / ☐Active ☐Vet ☐ROTC ☐National Guard ☐None ☐Other:
Country of Citizenship: / Ethnic Background:
Languages Spoken:
Religious or spiritual affiliation:
Are you a member of a fraternity or sorority? / ☐ / Yes / ☐ / No
Other organizations important to you:

How did you happen to come to Boynton Mental Health and/or Student Counseling Services (check all that apply):

☐ / Academic Advisor / ☐ / Dean (College) / ☐ / Mental health professional
☐ / Aurora Center / ☐ / Disability Resource Center / ☐ / Previous use
☐ / Boynton Health Services / ☐ / Faculty / ☐ / Stress Check-In
☐ / Clergy/Pastoral / ☐ / Family / ☐ / Student Counseling Services
☐ / College office or program / ☐ / Friend / ☐ / Student Conflict Resolution
☐ / Community Advisor/Res Hall Staff / ☐ / General knowledge / ☐ / Website

Student Counseling Services

340 Appleby Hall, 128 Pleasant Street SE, 612-624-3323

Personal Concerns Checklist

If you would like to receive personal counseling, please complete the following checklist.

If you would NOT like to receive personal counseling, skip this checklist and complete the Career Concerns and/or the Academic Concerns Checklist.

☐ Depression

☐ Anxiety

☐ Poor concentration

☐ Lonely, don’t feel connected

☐ Homesickness

☐ Lack self-confidence

☐ Irritable, angry

☐ Difficulty making decisions

☐ Feeling sad or blue

☐ Having problems with sleep

☐ Lack meaning in my life

☐ Problems with eating or food

☐ Concerned about my health

☐ Concerned about AIDS/HIV or other sexually transmitted infections (STIs)

☐ Concerned about financial problems

☐ Find it difficult to express my feelings, stand up for myself

☐ Concerned about my relationship with my partner

☐ Having difficulty with friends

☐ Concerned about relationships with parents and siblings

☐ Concerned about sex or sexual relationships

☐ Concerned I have caused harm to another person

☐ Feeling overwhelmed

☐ Bothered by troublesome thoughts

☐ Other:

Same-day walk-in crisis counseling is available if you are experiencing one or more of the following concerns.

Please check which of these apply, and indicate if you would like same-day walk-in crisis counseling:

☐ Concerned about alcohol or drug use

☐ Discrimination/hate crime

☐ Loss/death of a significant person

☐ Harassment/stalking

☐ Physical or emotional abuse

☐ Sexual assault, past or current sexual abuse

☐ Thoughts of harming myself or another person

☐ Have been accused of causing harm to another person

☐ Have deliberately injured myself

Do you want to meet with the walk-in crisis counselor on duty? ☐ Yes ☐ No

Student Counseling Services

340 Appleby Hall, 128 Pleasant Street SE, 612-624-3323

Career Concerns Checklist

If you would like to receive career counseling, please complete the following checklist.

If you would NOT like to receive career counseling, skip this checklist and complete the Personal Concerns and/or the Academic Concerns Checklist.

Increasing Self Awareness:

☐ Unsure where my real interests lie

☐ Don’t know what my strengths/abilities are

☐ Am unclear about the things/areas most important to me in a career/major

☐ Don’t feel my strengths/abilities match my interests

☐ Am confused about how my career fits into my life plans

Exploring Work Options:

☐ Am unsure about how my interests, values, personality and abilities relate to my choice of major or career

☐ Lack occupation information about job opportunities, duties or outlook

☐ Lack information about career resources available to me on campus

☐ Unsure about the type of environment in which I would like to work

Making Decisions About Careers:

☐ Feel lost and overwhelmed thinking about making a career/major decision

☐ Have difficulty making decisions

☐ Feel that personal circumstances/responsibilities (i.e family, relationships, finances) are interfering with my ability

to make a decision

Moving From Decisions To Actions:

☐ Am pretty sure what I want to do, but don’t know how to implement my decision

☐ Am anxious about taking steps necessary (e.g networking, interviewing) to successfully find employment

☐ Know what I want to do, but feel lack of support from people who are close to me

☐ Feel that my career planning is limited by physical or emotional problems

Student Counseling Services

340 Appleby Hall, 128 Pleasant Street SE, 612-624-3323

Academic Concerns Checklist

If you would like to receive academic counseling, please complete the following checklist.

If you would NOT like to receive academic counseling, skip this checklist and complete the Personal Concerns and/or the Career Concerns Checklist.

Are you on academic probation? ☐ Yes ☐ No

Are you returning from academic suspension? ☐ Yes ☐ No

Are you having significant concerns with academic performance or progress? ☐ Yes ☐ No

Below is a list of factors that can interfere with academic success and performance. Please check those that have been issues for your situation that you would like to discuss with a counselor.

Academic Skill Factors:

☐ Test-taking

☐ Memory/concentration

☐ Reading and comprehension

☐ Study skills

☐ Professor issues

☐ Lack of interest in courses

☐ Writing

☐ Note taking/listening

☐ Course demands (e.g. too much work)

Balance Factors:

☐ Family demands

☐ Work demands

☐ Overwhelmed

☐ Friends/social distractions

☐ Financial pressures

☐ Test anxiety

☐ Time management

☐ Distractions (TV, Internet)

☐ Procrastination

☐ Being over-involved

☐ Motivation

Health Factors:

☐ Physical health concerns

☐ Mental health concerns (anxiety, depression)

☐ Learning disability

☐ ADD/ADHD

☐ Sleep issues

Have you or anyone in your family ever been diagnosed as having a learning disability? ☐ Yes ☐ No

If yes, list the names and area(s) of learning disability (math, reading, etc.):

Student Counseling Services

340 Appleby Hall, 128 Pleasant Street SE, 612-624-3323

Availability Checklist

In order to facilitate therapist assignment, please indicate when you ARE available for an appointment.

NOTE TIMES YOU HAVE 45 - 50 MINUTES IN YOUR SCHEDULE FOR A COUNSELING APPOINTMENT.

What times ARE you available on MONDAYS?
☐ 8 AM
☐ 9 AM
☐ 10 AM
☐ 11 AM
☐ 12 PM
☐ 1 PM
☐ 2 PM
☐ 3 PM
☐ 4 PM
What times ARE you available on WEDNESDAYS?
☐ 8 AM
☐ 9 AM
☐ 10 AM
☐ 11 AM
☐ 12 PM
☐ 1 PM
☐ 2 PM
☐ 3 PM
☐ 4 PM
What times ARE you available on FRIDAYS?
☐ 8 AM
☐ 9 AM
☐ 10 AM
☐ 11 AM
☐ 12 PM
☐ 1 PM
☐ 2 PM
☐ 3 PM
☐ 4 PM / What times ARE you available on TUESDAYS?
☐ 8 AM
☐ 9 AM
☐ 10 AM
☐ 11 AM
☐ 12 PM
☐ 1 PM
☐ 2 PM
☐ 3 PM
☐ 4 PM
What times ARE you available on THURSDAYS?
☐ 8 AM
☐ 9 AM
☐ 10 AM
☐ 11 AM
☐ 12 PM
☐ 1 PM
☐ 2 PM
☐ 3 PM
☐ 4 PM

Rev. 9/01/17