AUCA Counseling Service
The information in Part A is requested for record-keeping and statistical purposes; it will not be used outside the Service in any way that identifies individuals. If you are completing this form electronically, you can type into the grey areas, which will expand to fit your answers. All the information you provide is strictly confidential.FirstName / Family Name
Date of birth
Mobile Phone / OK to phone? / Yes No
Home Phone / OK to phone? / Yes No
Email / OK to email? / Yes No
Student Status & Course Level / Undergraduate/BA Graduate/Masters Exchange
NGA Not Applicable
Current year of study 1 2 3 4 5 or more
Do you expect to graduate this year? Yes No
Gender / FM Transgender Prefer not to say
Nationality (country of permanent residence) / KRKazakhstanTajikistan
Other specify ______
Referred by: Who suggested that you came to see a counsellor?
Friend Academic Advisor
Family member Medical Office
PartnerOtherHave you used this Counseling Service before? / Yes No
Counsellor gender preference: Female Male No preference
Do you have a disability that you want us to know about? / Yes No
Current Medication, if any:
Other forms of help you have used previously or currently for related issue(s): / Previously / Currently
Other kind of specialist help
Please tick the boxes below to indicate your availability. We will try to offer an appointment when you are available but may offer non-preferred times to reduce the waiting period.
Very restricted availability is likely to delay counselling.
Term time:9am / 10 / 11 / 12 / 1pm / 2 / 3 / 4
Please sign to indicate that you have read the information about AUCA Counseling Service (available at:Signed
(or type name) / Date
Please continue to Part B
To be filled in by the Counseling Service:
Date form submitted:
Appointment arrangements made:
The information you provide will help us to understand your needs and arrange for you to see an appropriate counsellor, so it is useful to have some information about the problem. The questions are intended to be thought-provoking, but you do not need to give long answers or address every sub-question if it is irrelevant; it is also OK to put “I would prefer to talk about this in person” if it is difficult to write about.
This information will be treated confidentially.
1. Your reasons for approaching the Counseling Service
Please describe what has led you to your seek counseling now. How long has this been a problem for you — and what other help have you had with it? How do your current difficulties affect you?
2. What are you hoping for from counseling?
What would you like to gain from counseling now? How would things be different if the difficulties were resolved?
3. On a scale of 1 – 10 (with 10 being the most serious), how seriously is this affecting:
- Your quality of life
- Your academic performance
How have you been coping with this problem until now?
What support do you have in your life (e.g. family, friends, College, social activities)?
Do you have any difficulties with alcohol, drugs or food?
At your worst, do you ever feel like harming yourself or others?
5. Some of our work may involve workshops and groups of various kinds.
Please indicate whether these might interest you. Put ‘Yes’ or ‘No’.
- Structured groups with a focus on practical strategies:
- On-going/ad hoc counselling groups:
6. Is there anything else that you think is important which we should know?
If you have completed the form electronically, first save it and then email it as an attachment to:
If completed manually, take it to the AUCA Counselling Service Coordinator, Nelly Abrakhmanova, on the 4th floor, Room 415 (on the right).