Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet

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Griselda Hicks
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1 Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet Date: Student s Name: Student s ID: Local Address: Residence Hall & Room Number or Local Street Address Personal Phone: Alternate Phone: Permanent Address: Street Address, City, State/Country Birth date: Age: Year in School: (circle one) FY So Jr Sr Circle One: Female Male Female/Transgender MTF Male/Transgender FTM Genderqueer Questioning *What do you consider your racial or ethnic heritage to be? *Please indicate the country/countries of your citizenship: Referral Information: *Were you referred to Counseling Services by anyone? Y N If Yes, who? Concern Checklist: *Step 1: Check only those items that are of concern to you. Skip those that are not. *Step 2: For each checked item, circle the degree to which the concern is currently problematic. Mild Moderate Serious Severe 1. Relationship difficulties: breakup/loss of relationship; problems with romantic partner, friends or roommates 2. Family problems: divorce, separation, abuse; conflicts over money, roles, relationships or responsibilities 3. Depression/moods: depressed mood, loss of interest or pleasure, hopelessness; alternating periods of elevated and depressed mood 4. Suicidal thoughts or concerns: problems related to thoughts of suicide Anxiety: excessive or uncontrolled worry, nervousness, chronic fears, performance anxiety, panic attacks, social anxiety, obsessive thoughts, checking behaviors

Male/Transgender FTM Genderqueer Questioning *What do you consider your racial or ethnic heritage to be?

2 Page 2 6. Stress or psychosomatic symptoms: overwhelmed by circumstances, problems with headaches, stomach pains, etc. 7. Sleep: insomnia; frequent or premature waking Emotional regulation: concerns about managing anger or other difficult emotions 9. Academic difficulties: academic performance problems, missing classes College adjustment: problems adjusting to campus life, relationship between academics and future goals 11. Cultural adjustment: difficulties adjusting or readjusting to North American social customs and mores 12. Racial harassment: targeted by words or behaviors that interferes with full participation in community life 13. Self-esteem: concerns about self-image, shyness, insecurity Death or loss: grief related to loss of a valued other Existential/spiritual concerns: search for meaning in life, concern about the role of religion in one s life 16. Eating concerns and body image: purging, restricting, compulsive overeating, unhealthy dieting, excessive exercise, poor or inaccurate body image 17. Alcohol and/or chemical use: concerns about abuse or developing dependency on alcohol or other drugs 18. Addiction: other than chemical Self-inflicted harm: physical self-harm, i.e., cutting, burning, etc Sexual abuse, assault or harassment: Sexual orientation: concerns around issues related to sexual orientation Gender identity: concerns with how or whether to identify with a given gender label 23. Sexual health: concerns related to sexual behavior

College adjustment: problems adjusting to campus life, relationship between 1 2 3 4 academics and future goals 11.

3 Page Autism-Asperger spectrum: ADD/ADHD: attention deficit disorder / attention deficit hyperactivity disorder Physical disability: issues related to coping with aspects of a physical disability Medication: concerns or questions about the appropriateness of medications Other: *Areas of Impairment: Check the areas of your life that are most affected by your current symptoms or problems: 1. Class performance/attendance 5. Family relationships 2. Work performance/attendance 6. Physical health 3. Romantic relationships 7. Spirituality/religion 4. Friendships/social life 8. Other: Academic Information: Academic Major(s): Please list the courses you are taking this semester: *How would you describe your overall academic performance at Macalester? Excellent Good Fair Poor *Are you currently on academic probation or warning? Y N *Are you currently on social probation or warning? Y N Have you attended any other colleges? Y N If Yes, please list the college name, city, state, country, and year(s) of attendance:

Other: 1 2 3 4 *Areas of Impairment: Check the areas of your life that are most affected by your current symptoms or problems: 1. Class performance/attendance 5. Family relationships 2.

4 Page 4 Employment and Other Extracurricular Activities: *Are you currently employed? Y N If Yes, where? How many hours/week do you work? *Are you currently involved in any volunteer activities, student organizations, internships etc.? Y N If Yes, where? How many hours/week are involved? *Are you currently involved in any regular sports activity, including varsity, club or intramural sports? Y N If Yes, what sport? How many hours/week are involved? Family Background: Please list the following information about your family members: Name Age Occupation * Status: (married, cohabitating, separated, divorced, remarried, deceased) Parent Parent Stepmother Stepfather Siblings *Please indicate any family history of the following: (Check all that apply) 1. Physical abuse 4. Depression, anxiety, or psychological difficulties 2. Emotional or verbal abuse 5. Medications for psychological difficulties 3. Sexual abuse 6. Problems with alcohol or other drugs 7. None of the above *Please indicate if you personally have been the target of any the following: (Check all that apply) 1. Physical abuse 3. Sexual abuse 2. Emotional or verbal abuse 4. None of the above

*Are you currently involved in any regular sports activity, including varsity, club or intramural sports? Y N If Yes, what sport? How many hours/week are involved?

5 Page 5 Health History: How would you describe your overall physical health? (circle one) Excellent Good Fair Poor Have you ever had any chronic health conditions, major illnesses, serious injuries, or significant head trauma? Y N If Yes, please describe: *Do you have a diagnosed pre-existing mental health condition? Y N If Yes, please specify: *Do you have any previous experience with counseling? Y N If Yes, please list the approximate date(s), and issues discussed (optional): Do you regularly take any medications, including over-the-counter medications? Y N If Yes, please list the name(s) and dosage(s): *Are any of these medications for psychological difficulties? Y N Is your medication being monitored by an M.D. or other health care professional? Y N *Have you ever been hospitalized for psychological problems? Y N If Yes, please describe what happened and give the date(s): *Have you ever attempted suicide? Y N If Yes, please describe what happened and give the date(s): Eating Concerns: Have you ever had significant concerns about your eating habits? Y N Have friends, doctors, your parents, or others ever told you they were concerned about your eating habits? Y N

Y N If Yes, please describe: *Do you have a diagnosed pre-existing mental health condition? Y N If Yes, please specify: *Do you have any previous experience with counseling?

6 Page 6 *Have you ever been treated for an eating disorder? Y N If Yes, please describe the nature of the treatment and give the approximate date(s): Alcohol and Other Drug Use: *Please check the box that best describes your current use of the following: 6 or More 4-5 Times 2-3 Times Once 1-3 Times Once a No Times a Week A Week A Week A Week A Month Month or Less Current Use Alcohol Marijuana _ (Other, please list) _ (Other, please list) When you drink alcohol, how many drinks do you typically have? Have you ever thought that you had a problem with alcohol or other drug use? Y N Has anyone else ever thought you had a problem with alcohol or other drug use? Y N *Have you ever sought treatment? Y N If yes, please describe the nature of the treatment and give the approximate date(s): Lifestyle Checklist: *Do you use caffeine? Y N *Do you use tobacco? Y N *Do you exercise? Y N *Are you satisfied with the quality and quantity of sleep? Y N

More 4-5 Times 2-3 Times Once 1-3 Times Once a No Times a Week A Week A Week A Week A Month Month or Less Current Use Alcohol Marijuana _ (Other, please list) _ (Other, please list) When you drink

7 Page 7 Goals for Counseling: Please list the goals you wish to achieve in counseling, for example problems you wish to solve or coping skills you would like to learn: Thank you for taking the time to complete this questionnaire. If you have any questions or concerns, please ask your counselor during your first visit.

like to learn: Thank you for taking the time to complete this questionnaire.

8 Page 8 This Page For Office Use Only Date of Intake: Student s Name: Student s ID: Counselor: Don DeBoer /Henry Emmons /Michaela McLaughlin /Randall Morris-Ostrom /Mia Nosanow /Ted Rueff /Brooke Skinner-Drawz Services: (Check one only) Scheduled Intake Interview: 1. Intake 2. Late cancel (< 24hrs) 3. Early cancel (>24hrs) 4. No show 5. Office cancel Drop-In Intake Interview: 9. Intake interview Disposition: (Check all that apply) 1. Return appointment scheduled for: STNW or 2. Referred to another counselor on staff 3. Returned to wait list 4. Referred to drop-in appointments as needed 5. Counseling ended 6. No show letter sent/phone call made Off-campus referrals to: 1. Medication assessment/treatment 2. Personal counseling 3. Other physical/medical treatment On-campus referrals to: 1. HWC Support Group 2. Advisor or Faculty Member 3. Leonard Center Health and Recreation 4. Career Development Center 5. Center for Religious and Spiritual Life 6. Dean of Students 7. Disability Services 8. International Center 4. Chem. dep. assessment/treatment 5. Eating disorder assessment/treatment 6. Learning disability assessment 7. Other: 9. Lealtad-Suzuki Center 10. Macalester Academic Excellence (MAX) Center 11. Medical Services (general medical) 12. Medication Assessment 13. Student Orgs / Activities 14. Residential Life 15.Civic Engagement Center 16.Other_ Rev. 08/8/13

Intake interview Disposition: (Check all that apply) 1. Return appointment scheduled for: STNW or 2. Referred to another counselor on staff 3. Returned to wait list 4.

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer: