Intake Form Part 1 - Lee University

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