Name: Today S Date: Age: Date of Birth

Welcome to UW’s GME Resident and Fellow Wellness Service! Before we begin our first counseling appointment, please take 1-2 minutes to complete the information below and return it electronically to Pam, Kristi or Mindy. If you are attending as a couple, I’d like each of you fill one out.

All information will be kept confidential and stored in a secure location. Thank you – we look forward to meeting you!

Name: Today’s Date: Age: Date of Birth:

Date and Time of your First Appointment: Counselor: Pam, Kristi or Mindy

Please check one: ____I am a resident

____I am a fellow

____I am a spouse/partner

Program: ______PGYear:______

(If your significant other is a resident/fellow, tell us their name, program and program year)

Home Address: City, State, Zip:

Email Address: OK to contact by email? No Yes

Best Phone Number to Reach You: OK to leave a message? No Yes

Pager:

Partner/Spouse Name:

Emergency Contact #1: Cellphone:

Relationship to you?

Emergency Contact #2: Cellphone:

Relationship to you?

How did you hear about our program?

Have you been referred by your program director? Yes No Name?

What is the primary reason for which you are seeking help today?

Have you had prior counseling? No Yes

If so, did you receive a diagnosis? No Yes

If you answered “Yes” to the above question, did you take any psychotropic medication for this condition? No Yes

What is the current amount you (and/or your significant other) owe for your education?