Counseling & Psychological Assessment
Basic Information
Name (First and last)
Phone Number
Date of birth
Email
Gender
Student ID#
Academic Status:
Undergraduate 1st year
Undergraduate 2nd year
Junior/3rd year
Senior/4th year
Have you had counseling/psychotherapy in the past?
Yes
No
When
Have you taken psychiatric medicine in the past?
Yes
No
Have you ever been psychiatrially hospitalized?
Yes
No
When
Are you currently receiving counseling or therapy?
Yes
No
When and the date of your next appointment
Are you currently taking prescribed psychiatric medications?
Yes
No
Please specify what
Have you ever had thoughts of harming yourself?
Yes
No
Have you had suicidal thoughts in the past year?
Yes
No
Have you ever purposely injured yourself without a suicidal intent?
Yes
No
Have you ever made a sucide attempt?
Yes
No
When
Do you have current thoughts about harming someone?
Yes
No
Have you ever intentionally physically harmed someone?
Yes
No
Are you having strange experiences such as hearing voices or seeing things others do not see or hear?
Yes
No
Are you having difficulty coping with the recent death of someone close to you?
Yes
No
Contact Information
