CMHS Confidential Student Information Form

Date: ______Tufts ID#: ______Health Insurance Information: ______

Name: ______Preferred Name (If different):______

Date of Birth: ______Age: ______Phone: ______

Email: ______Please note: Your clinician will contact you through the secure portal.

Local address: ______

Permanent Address/Phone: ______

Emergency contact information: (Name, Relationship, Address & Phone)
______

Month and year you entered Tufts: ______Current Class Year: ______

Major/Area of Study: ______

Gender Identification: ______Pronouns: ______

Current Relationship/Marital Status: ______

How do you usually describe your race and/or ethnicity? / How do you usually describe your sexual orientation?
  • White or Caucasian, non-Hispanic, Non-Arab
/ oLesbian
  • African American/Black, non-Hispanic
/
  • Gay

  • Hispanic/ Latino
/
  • Bisexual/Pansexual

  • American Indian/Alaskan Native
/
  • Asexual

  • Arab/Middle Eastern or Arab American
/
  • Heterosexual

  • Asian/Asian-American
/
  • Queer
  • Questioning
  • Other______
  • Non applicable-I would prefer not to identify

  • Pacific Islander
  • Other (Specify) ______
  • Non applicable-I would prefer not to identify

Are you an international student? No / Yes If yes, what is your country of origin? ______

Please list parents, siblings, and other significant family members below:

Family relationship: Age:Occupation: Education:

______

If there are any other significant people in your life (e.g., friends, partners, mentors, etc.), please list them here:

______

______

Are you currently or have you ever been to counseling or had mental health treatment before?

No Yes (If Yes, Please Describe) ______

______More questions on opposite side 

Have you or any family member had a history of medical, mental health, or substance abuse issues?

No Yes (If Yes, Please Describe)

______

List any medications including dosages, purpose, prescriber and how long you have been taking them:

______

Are you currently experiencing any of the following? (Please check all that apply)

⃞Stress / ⃞Irritable / ⃞Racing thoughts / ⃞Anxious / ⃞Hopeful
⃞Success / ⃞Worthless / ⃞Appetite Changes / ⃞Nightmares / ⃞Happy
⃞Adjustment/Transition / ⃞Mood swings / ⃞Feeling helpless / ⃞Worthwhile / ⃞Being good to yourself
⃞Relationship issues / ⃞Guilty / ⃞Unmotivated / ⃞Abuse Issues / ⃞Feeling connected
⃞Family concerns / ⃞Low self-esteem / ⃞Acting Impulsive / ⃞Lonely / ⃞Feeling loved
⃞Homesick / ⃞Isolated / ⃞Sleep Changes
(more/less) / ⃞Self harm (cutting, scratching, burning) / ⃞Physically active
⃞Skipping class / ⃞Numbness / ⃞Shopping sprees / ⃞Purging / ⃞Relaxed
⃞Grief/Loss / ⃞Poor
concentration / ⃞Too much time
online / ⃞Eating concerns / ⃞Questions about sexuality
⃞Identity issues / ⃞Crying easily / ⃞Binge drinking / ⃞Trauma / ⃞Cultural adjustment
⃞Confused / ⃞Procrastination / ⃞Using drugs / ⃞Angry / ⃞Concerns about
sexual behavior/health
⃞Worried about future / ⃞Academic
difficulties / ⃞Chronic health
issues / ⃞Unpleasant thoughts
that won’t go away / ⃞Paranoid
⃞Conflicts with friends / ⃞Being reckless / ⃞Excessive use of
medicine / ⃞Harassment
⃞Being
threatened / ⃞Body image
concerns / ⃞Other______

Please briefly describe what is happening in your life that prompted this appointment:

______

Please briefly list any recent major changes in your life:

______

What are you hoping to accomplish in therapy at this time?

______

Is there anything else that we did not ask that you feel we should know about you?

______

______

INFORMATION PROVIDED TO COUNSELORS IS CONFIDENTIAL WITHIN THE LIMITS OF OUR INFORMED CONSENT AGREEMENT. PLEASE REVIEW ACCOMPANYING CONFIDENTIALITY POLICY.