COUNSELING SERVICES INTAKE FORM ... - Aurora University

COUNSELING SERVICES INTAKE FORMFile # __________Have you been to Aurora University Counseling Services before? Yes NoContact Information:Name: ________________________________________________ Today’s Date: _____________(First) (Middle) (Last)School Address: ______________________________________________________________________(Building) (Room No.) (Unit No.)Permanent Address: ___________________________________________________________________(Street) (City) (State) (Zip)Local phone: _______________ Other phone: ________________ Email: _____________________May we communicate with you by e-mail? Yes NoHow did you learn of our services and/or who referred you to us (source of referral)?____________________________________________________________________________________Emergency contact: Name__________________________________ Phone_______________________Date of Birth: _______________________ Age:________ Gender:__________________________eerertyRace (Check all that apply): Asian/Pacific Islander African-American/BlackHispanic/Spanish OriginNative AmericanWhite (non-Hispanic)OtherAre you a(n): International Student? Yes No If yes, from where?_______________________Student Athlete? Yes No If yes, which sport(s)______________________Greek Member? Yes No If yes, which organization?_________________Transfer Student? Yes No If yes, from where?_______________________Military Veteran? Yes No If yes, which branch?_____________________Class: FY SO JR SR Graduate StudentCurrent G.P.A.______ Total Credit Hours: ________ Major:______________________________Full-timePart-timeFamily/Relationship Information:List the members of your immediate family, may include mother, father, sisters, brothers, spouse/partner,and children.Relationship Name Age OccupationCheck here ifdeceased

Are you in a significant relationship (dating, engaged, married/partnered)? Yes NoBriefly described why you have chosen to seek Counseling Services at this time:__________________________________________________________________________________________________________________________________________________________________________________________________________________Treatment and Medical Information:Are you currently receiving or have you previously received services from a counselor/mental healthprofessional? Yes NoIf yes, please list provider name and date(s) of treatment:________________________________________________________________________________________________________________________________________________________________________Please list any medical conditions that you have or believe you might have:________________________________________________________________________________________________________________________________________________________________________Please list any medications which you are currently taking: _____________________________________________________________________________________________________________________________________________________________________________________________________________Counseling ServicesAurora University Counseling Services provides short-term personal counseling (individual and couples),assessment, consultation and referral services, which are confidential and free of charge. Only currentlyenrolled students at Aurora University are eligible for these services. Depending upon the nature of yourconcern, current service demands or other circumstances, your counselor may refer you to another healthcare provider(s) who can better meet your needs.Client Rights• You have the right to be treated with dignity and respect without regard to your race, color,religion, national origin, gender, age, sexual orientation, or disability.• You have the right to have your counselor explain the way in which your confidential mentalhealth information will be handled and the limitations of confidentiality.• You have the right to request a specific counselor, request a different counselor than the oneassigned to you, or ask for a second opinion.• You have the right to receive an appropriate referral for community mental health services if yourequest one or if your needs exceed what we are able to provide you.• You have the right to work collaboratively with your counselor in establishing treatment goals.• You have the right to ask questions about your counselor’s qualifications, credentials, andtheoretical orientation, as well as any counseling and testing techniques/procedures utilized.• You have the right to refuse or terminate treatment.• You have the right to review with your counselor the records in your personal file maintained byCounseling Services, including diagnosis and test results.• You have a right to request a copy of records generated by our office. Typically, you will be askedto meet with your counselor to review the records before they are released to you.

Client Responsibilities• You should make every effort to arrive on time for appointments.• You should notify Counseling Services if you are unable to keep a scheduled appointment.Clients who consistently miss appointments without notification may have those servicesterminated or restricted.• You are expected to arrive for appointments without being under the influence of drugs or alcohol.ConfidentialityRecords maintained by Counseling Services are considered medical records and protected healthinformation. As such, these records are kept separate from all other student records. This means thatwhat you tell or otherwise share with your counselor and the Counseling Services staff will remainconfidential. Consultation with individuals or organizations outside Counseling Services, including faculty,family, or friends require your written consent. There are, however, some exceptions and limitations toconfidentiality as required by law. Please carefully review the Policy of Confidentiality form and speakwith your counselor if you have any questions.I, __________________________________, have read and understand the nature of counselingservices, rights and responsibilities, and confidentiality. I have received a copy of the Policy ofConfidentiality which provides a detaileddescription of the potential uses and disclosures of my protected health information, as well as my rightson these matters.__________________________________________Student Signature___________________________Date

Not at allA little bitModerateQuite a bitExtremelyNot at allA little bitModerateQuite a bitExtremelyList of possible current concernsPlease rate how concerned you are about each of the followingPlease rate how concerned you are about each of the following:Adjusting to college 0 1 2 3 4Alcohol/drugs 0 1 2 3 4Anger management 0 1 2 3 4Anxiety/worry 0 1 2 3 4Assertiveness 0 1 2 3 4Communication 0 1 2 3 4Death/grief/loss 0 1 2 3 4Depression 0 1 2 3 4Decision making 0 1 2 3 4Eating problems 0 1 2 3 4Emotional abuse 0 1 2 3 4Expressing feelings 0 1 2 3 4Family problems 0 1 2 3 4Financial problems 0 1 2 3 4Goal setting/attaining 0 1 2 3 4Identity 0 1 2 3 4Legal problems 0 1 2 3 4Meeting people 0 1 2 3 4Panic attacks 0 1 2 3 4Physical abuse 0 1 2 3 4Pregnancy issues 0 1 2 3 4Relationships 0 1 2 3 4Religion 0 1 2 3 4Self-esteem 0 1 2 3 4Sexual abuse/assault 0 1 2 3 4Sexual orientation 0 1 2 3 4Sexuality 0 1 2 3 4Sleep problems 0 1 2 3 4Stress 0 1 2 3 4Suicidal thoughts 0 1 2 3 4Academic / educationalChoosing a major 0 1 2 3 4Grades/probation 0 1 2 3 4Learning disability 0 1 2 3 4Procrastination 0 1 2 3 4Staying in/leaving school 0 1 2 3 4Study skills 0 1 2 3 4Test anxiety 0 1 2 3 4For Office Use OnlyDate:____________________________Total________________Academic Total____________________

Policy of ConfidentialityFor Mental Health ServicesIt is important for you to know that any information disclosed during your contacts withCounseling Services will be confidential (even if you were judicially referred), as required byfederal and state law, as well as ethical standards.In order the ensure the highest quality of care, though, at times the counselor may needto consult with other qualified mental health providers regarding issues you are working on.When the mental health providers are part of AU’s Counseling staff, every effort will be madeto protect your identity and any information shared will remain within the Counseling staff, asrequired by each professional’s code of ethics and the law.At times when it may be appropriate to discuss information with designated othersoutside of AU Counseling Services regarding your concerns and care, you always will beasked to sign a release form to permit this exchange of information. The request forinformation sharing between Counseling Services and other people may be initiated by you orby your counselor. You have the right to deny a request. The release form may be requestedfor people in other offices within the University, such as Deans’ offices, Residence Life, theRegistrar’s office, the Provost or the President. Sharing information with parents, guardians,other relatives, partners or employers also requires a release form to be signed.According to Illinois law, you need to be aware of a few exceptions to the rules ofconfidentiality. If it is determined that you may seriously harm yourself or someone else,counselors have a duty to warn and take action. In these cases, the rights of confidentialityare suspended. Counselors also are required by state law to report to appropriate agenciesany instance of suspected child, elder or other abuse to individuals unable to care forthemselves. In all cases, your counselor will make every effort to discuss and resolve theseissues with you before any action is taken.A confidential record of your counseling contact is retained by CounselingServices and will be destroyed after seven years. It includes your Student Information Sheet(filled out above), the number of counseling sessions, and a brief summary of what broughtyou to counseling and the outcome. Again, this record stays at the Counseling Services officeand does not become a part of your University record.If you have any further questions about confidentiality and privacy, please ask yourcounselor.By signing below, you consent to receive counseling services and fully understand theconditions under which services will be provided.Student Signature____________________________________Date_________________Provider signature____________________________________Date_________________