STUDENT APPLICATION FORM

  • Your application and all of the information on this form will be kept confidential, andwill not be shared with anyone outside PCU.
  • Your application will be directed to a counselor as soon as possible and you will be contacted for an appointment. During busy periods,this process may take 2-4 weeks. Providing most alternatives for your available days and hours at the end of thisform will facilitate your appointment process.
  • In case of emergencies, it is recommended to apply to PCU offices during working hours, outside the working hours it is recommendedto reach out to the nearest health facility.
  • Frequency and duration of the sessions are decided on the basis of your needs and expectations, your application period and suitability of the unit. For your needs that are outside the scope of unit’s assistance areas and working conditions and/or for long-term psychological help needs, referrals are made to reliable and low-cost help sources.
  • If you fail to show up for your initial appointment, it will be assumed that you have decided not to receive help from the PCU. In such cases, it is your responsibility to contact the unit and activate your application if you would like to receive help.
  • For any questions regarding the process you can contact PCU administrative assistant at or 212-351 7674.

Name-Surname: / Date of Application:
Phone number(s): / e-mail:
Gender: Female  Male / Date/Place of Birth:
Department: / Year of enrollment at BİLGİ:
Grade:  Prep 1. 2. 3. 4. Masters Doctorate
Scholarship Status:  Full Partial No scholarship
Marital Status: Single Married Divorced Other
Where/Whom are you living with?  Family  Friend/Partner  Alone  Dorm  Other
Have you applied to PCU before?  No  Yes
If yes, Who was your counsellor?
When?
How long did you attend sessions?
Have you ever received psychological/psychiatric help outside the school?  Yes  No
If yes, Who was your counsellor?
When?
How long did you attend sessions?
Is there a psychiatric drug that you regularly use?  Yes  No
If yes, please provide names and dosage:
How did you decide to apply to PCU?
 Own Decision Referral by faculty Referral by administrative staff Referral by a friend Referral by family Referral by an expert outside school
Reason for applying PCU:
Academic problems Family problems Romantic/Social relationship problemsUnhappiness/Anxiety Physical complaints Personality traits Alcohol/Substance Abuse
Loss/Trauma Other
Please briefly state your complaints:
For how long you have been experiencing these complaints?
Last 1 month  3-6 months  6 moths-1 year  1-5 years more than 5 years
How much effect these complaints have on your daily life?
 1 (None/Very little)  2 (Little)  3 (Moderate)  4 (Significant)  5 (Highly significant)
How much support are you able to get from your family/friends for these complaints?
 1 (None/Very little)  2 (Little)  3 (Moderate)  4 (Significant)  5 (Highly significant)
Your expectation from psychological help:
Guidance/Counseling Short term psychotherapy/counseling
Long term psychotherapy/counseling Other
Please briefly state your expectation:
Please state your campus preferences as 1., 2. and 3.,
Due to appointment overload you may be referred to campuses other than yours.)
___ Dolapdere ___ Kuştepe ___ santralistanbul
Please state which days and time slots you will be available on?
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday

(THIS SECTION WILL BE FILLED BY THE PCU STAFF)

Received by:Referred to:

Referral Date:Referred by: