Intake Form Part 1 - Lee University

INTAKE QUESTIONNAIREPlease fill in or circle the appropriate responses to the following questions. You may leave any item blank or discuss any item with acounselor before answering. All information is protected under the confidentiality policies noted above.Full Name: Maiden Name: Today’s Date:Local or Cell Phone:Please check here if we may NOT leave a message at this number:Email Address:Please check here if we may NOT leave a message at this address:Local Mailing Address:Residence Hall and Room Number:Emergency Contact: By listing the contact information below and initialing here, you are giving the LUCC permission tocontact this person in the event of a physical or mental health emergency including but not limited to a life-threatening situation, aclient’s death/incapacitation, or imminent risk of harm to self/others should such contact be deemed beneficial by the appropriateLUCC staff member(s):Emergency Contact Name: Phone: Relationship:Date of birth: / / Age:What is your gender identity: Woman Man Transgender Self-identify (please specify):What is your race/ethnicity:African American/Black American Indian or Alaskan Native Asian American/AsianHispanic/Latino/a Native Hawaiian or Pacific Islander Multi-racialWhiteSelf-indentify (please specify):Do you consider yourself:Heterosexual Lesbian Gay Bisexual Questioning Self-identify (please specify):Are you an international student? Yes / NoIf yes, what is your country of origin?Relationship Status:Single Serious dating or committed relationship Civil Union, Domestic Partnership, or EquivalentMarried Separated Divorced WidowedCurrent Academic Status:Freshman/ First Year Sophomore Junior Senior Graduate student Non-studentHigh school student taking college classes non-degree student Faculty or StaffOther (please specify):What is your academic major?Graduate or Professional Degree Program (Specify):What year are you in your graduate program? 1 2 3 4 5+What is your current GPA?Are you registered with the Office of Academic Support on this campus as having a documented and diagnosed disability?Yes / NoIf you selected “yes” for the previous question, please indicate which category of disability you are registered for(Circle all that apply):Attention Deficit/Hyperactivity Disorder Deaf or Hard of Hearing Learning DisordersMobility Impairments Neurological Disorder Physical/Health Related DisorderPsychological Disorder/ Condition Visual Impairment Other (please specify):

Did you transfer from another campus/institution to this school? Yes / NoWhat kind of housing do you currently have?On-campus residence hall/apartment Off campus apartment/house Other (please specify):With whom do you live?Alone Spouse, partner, or significant other Roommate(s) ChildrenParents or guardian Family other Other (please specify):Do you participate on an athletic team that competes with other colleges or universities?Yes / NoPlease estimate your level of involvement in organized extra-curricular activities (e.g., sports, clubs, student government, etc.):None Occasional Participation One Regularly Attended ActivityTwo Regularly Attended ActivitiesThree or More Regularly Attended ActivitiesPlease indicate the number of hours per week you are actively involved in organized extra-curricular activities (e.g., sports,clubs, student government, etc.):What is the average number of hours you work per week during the school year (paid employment only)?Have you ever served in any branch of the US military (active duty, veteran, National Guard, or reserves)? Yes / NoDid your military experiences include any traumatic or highly stressful experiences which continue to bother you? Yes / NoIf yes, please describe:Are you the first generation in your family to attend college? Yes / NoHow would you describe your financial situation right now?Always Stressful Often Stressful Sometimes Stressful Rarely Stressful Never StressfulHow would you describe your financial situation while growing up?Always Stressful Often Stressful Sometimes Stressful Rarely Stressful Never StressfulReligious or spiritual preference:Agnostic Atheist Buddhist Catholic Christian Hindu JewishMuslim No preference Self-identify (please specific):To what extent does your religious or spiritual preference play an important role in your life?Very important Important Neutral Unimportant Very unimportantThink back over the last two weeks. How many times have you had: five or more drinks* in a row (for males) OR four ormore drinks* in a row (for females)?*A drink is a bottle of beer, a glass of wine, a wine cooler, a shot glass of liquor, or a mixed drink.None Once Twice 3 to 5 times 6 to 9 times 10 or more timesThink back over the last two weeks. How many times have you smoked marijuana?None Once Twice 3 to 5 times 6 to 9 times 10 or more timesPlease indicate if and when you have had the following experiences:Attended counseling for mental health concerns: Never Prior to College After Starting College BothTaken a prescribed medication for mental health concerns: Never Prior to College After Starting College BothIf you have previously or are currently taking any prescription medication(s) for mental health concerns, please listthe type, dosage, prescribing physician, and purpose of each here:

Please indicate if and when you have had the following experiences: How many times? The last time?Been hospitalized for mental health concernsNever1 time2-3 times4-5 timesMore than 5 timesNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsFelt the need to reduce your alcohol or drug useOthers have expressed concerns about your alcohol or drug useReceived treatment for alcohol or drug usePurposefully injured yourself without suicidal intent (e.g., cutting, hitting, burning,etc.):Seriously considered attempting suicideMade a suicide attemptConsidered causing serious physical injury to another personIntentionally caused serious physical injury to another personSomeone had sexual contact with you without your consent (e.g., you were afraidto stop what was happening, passed out, drugged, drunk, incapacitated, asleep,threatened or physically forced)Never1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years ago

Experienced harassing, controlling, and/or abusive behaviorfrom another person (e.g., friend, family member, partner, orauthority figure)Experienced a traumatic event that caused you to feel intense fear, helplessness, orhorrorNever1 time2-3 times4-5 timesMore than 5 timesNever1 time2-3 times4-5 timesMore than 5 timesNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoNeverWithin the last 2 weeksWithin the last monthWithin the last yearWithin the last 1-5 yearsMore than 5 years agoIf you selected “yes” for the previous question, please briefly describe the event(s):Please select the traumatic event(s) you have experienced:Childhood physical abuse Childhood sexual abuse Childhood emotional abusePhysical attack (e.g., mugged, beaten up, shot, stabbed, threatened with a weapon)Sexual violence (rape or attempted rape, sexually assaulted, stalked, abused by intimate partner, etc.)Military combat or war zone experiencesKidnapped or taken hostageSerious accident, fire, or explosion (e.g., an industrial, farm, car, plane, or boating accident)Terrorist attack Near drowning Diagnosed with life threatening illnessNatural disaster (e.g., flood, quake, hurricane, etc.)Imprisonment or tortureAnimal attackOther (please specify):Please indicate how much you agree with this statement: “I get the emotional help and support I need from my family.”Strongly Disagree Somewhat Disagree Neutral Somewhat Agree Strongly AgreePlease indicate how much you agree with this statement: “I get the emotional help and support I need from my social network(e.g., friends and acquaintances).”Strongly Disagree Somewhat Disagree Neutral Somewhat Agree Strongly AgreePlease list the name(s) and contact information of any treatment providers/agencies of psychiatric and/or mental healthservices and COMPLETE A SEPARATE RELEASE so that the LUCC may obtain treatment information/records from pastproviders as needed:In the space below, please briefly describe the concerns that prompted you to talk with an LUCC staff member today:Health Insurance I have health insurance: Company Name I DO NOT have health insurance I do not know if I have health insurance

CROSS OUT all appointment times for which you would be UNAVAILABLE for counseling on a regular basis due to class,work, etc. Please note that the more availability you provide, the more likely it is that your schedule will match the schedule of anLUCC counselor.M 8:15 9:15 10:15 11:15 1:15 2:15 3:15 4:15T 8:15 9:15 1:15 2:15 3:15 4:15W 8:15 9:15 10:15 11:15 1:15 2:15 3:15 4:15Th 8:15 9:15 1:15 2:15 3:15 4:15F 8:15 9:15 10:15 11:15 1:15 2:15 3:15 4:15

SIGNATURE PAGEYou may discuss any of the following with a counselor before signing.I have completed this form truthfully and attest that I am entering into counseling voluntarily. I have read and understand ALL of theabove information, and I am fully aware of my rights, the benefits, and risks that counseling may present. I am also fully aware of thelimits to confidentiality. Should I have any questions or concerns about any of this information, I agree to discuss these promptly withmy counselor.SignatureDateLUCC participates in a national research project designed to improve our services and expand the knowledge about college studentmental health. We participate by contributing anonymous, numeric data provided by those who use our services (and are over 18 yearsold) to a database managed by researchers at Penn State University. Data is stripped of all personally identifying information and thencombined with anonymous, numeric data from other colleges nationwide for statistical analysis. Because data cannot be linked tospecific individuals, there are virtually no risks contributing data. With your permission, we would like to contribute anonymous,numeric data from the questionnaires you just completed. Your decision is voluntary and will not affect the services you receive. Ifyou have questions or concerns, you may contact Dr. David Quagliana, LUCC Director at dquagliana@leeuniversity.edu. Yoursignature below indicates permission for the LUCC to contribute ANONYMOUS data as described above.SignatureDateSupervised Staff Members and Release to Record Sessions:Some clinical staff members of the LUCC are graduate-level interns, under the direct supervision of licensed mental health clinicians.Individuals who are en route to professional licensure as psychologists, counselors, or marriage/family therapists are required to beunder supervision and must report their clinical activities to their supervisor(s). All staff members under supervision are also requiredto disclose their level of training and the name of their clinical supervisor(s) to clients.Audio or video recording of your sessions can help you, the supervised staff member, and the supervisor(s) to review the course andprocess of your counseling. Therefore, you are encouraged, but not required, to allow the recording of some or all of your sessions.The recordings will only be reviewed by your counselor and his/her clinical supervisor. You may request that the recorder be turnedoff at any time and may request that the file or a portion of it be erased immediately. Recordings are to be used for your treatmentand/or supervisory purposes only. Files will never be removed from the building and will be erased promptly.I understand that my counselor MAY be under the supervision of a licensed professional. I grant permission for my counselor torecord my counseling sessions.SignatureDateFor Couples Counseling ONLY:Due to the significantly high demand for services and limited resources available, clients may choose to receive individual or couplescounseling at the LUCC, but may not be involved in both simultaneously. To receive couples counseling, at least one member of thecouple must be a currently enrolled Lee University student. Regarding records, because the counseling record belongs to the couplerather than the individuals, both members must give written consent before any records can be released. Non-students agree that theyare eligible to receive couples counseling ONLY and further agree to accept an appropriate outside referral should individual mentalhealth needs take precedence over the couples counseling or should it be determined that individual counseling would be moreappropriate for either member. By accepting a non-student member of a couple for couples counseling, the LUCC is in no way takingclinical responsibility for the mental health needs of the non-student member as an individual.Signature – LEE UNIVERSITY STUDENTDateSignature – NON-STUDENTDate