Clinical Counseling Services Intake Form - Lawrence Technological ...

If yes, please list provider and dates:Provider:Dates: from toNotes:Have you ever been hospitalized? Yes NoHave you had suicidal ideation or suicide attempts? Yes NoDo you have any medical conditions? Yes NoPlease Describe:What is your current living arrangement?Are you taking any medications at this time? Yes NoIf yes, please describe:Do you have medical insurance? Yes NoIf yes, what kind?Confidential Student Information- 2 -Protected by FERPA