Intake and Informed Consent

Oasis Counseling Center - Client Intake Form

Welcome to the Oasis counseling center at Cairn University. Please complete the following form and bring it with you to your first appointment. All information is confidential.

Date: ID#: Referred by:

Name: Date of Birth: Age:

Mailing Address:

Phone (Cell): (May we call or leave a message?) Y N

Phone (Home): (May we call or leave a message?) Y N

E-mail Address: (May we e-mail you?) Y N

Roommates(s): (1) (2)

(3) (4)

Employment: Hrs. per week:

ACADEMIC INFORMATION:

Classification: Hours attempted this semester: Overall GPA:

Expected Date of Graduation: Major:

Probable Occupation:

Relationship Status: Single Dating Engaged Married Divorced

Local Church: Home Church:

What brings you to counseling?

How severe do you believe this problem is? Mildly Upsetting Very Upsetting Urgent, I’m in crisis

How would you rate the level of emotional pain you are currently experiencing?

Mild Moderate Extreme

Have you ever sought counseling before? Yes No

If so, please explain:

Are you currently experiencing any suicidal thoughts? Yes No

If yes, please explain:

Rate overall risk of suicide

Extremely low risk: 1 2 3 4 5 : Extremely high risk

Have you ever experienced suicidal thoughts/actions in the past? Yes No

If yes, please explain:

How would you assess your current physical health? Very Good Good Fair Poor

Explain:

How often do you exercise?

Describe your sleeping patterns:

How often do you eat?

How much caffeine do you take in per day?

Are you currently taking any prescription medication? Yes No

Medication 1: Prescribed for: Dosage (mg./day):

Medication 2: Prescribed for: Dosage (mg./day):

Medication 3: Prescribed for: Dosage (mg./day):

Have you ever had surgery? Yes No

If yes, when and what for?

Do you have a history of alcohol or drug use? Yes No

If yes, please explain:

Treatment?

FAMILY HISTORY: (Check any that are/were present in your family.)

Depression

Anxiety

Substance Abuse

Suicide Attempt

Physical Abuse

Sexual Abuse

Eating Disorder

Other Psychiatric/Emotional Disturbance (explain)

None

Please check any of the following concerns you are currently experiencing or have experienced:

Present Past Anxiety

Present Past Depression

Present Past Bipolar disorder

Present Past Unwanted sexual experience

Present Past Sleep disturbance

Present Past Changes in appetite

Present Past Academic problem

Present Past Relationship concerns (e.g. break up, conflict)

Present Past Relationship violence (e.g. emotional, physical, sexual, verbal abuse)

Present Past Panic attacks

Present Past Shyness or Social Anxiety

Present Past Test Anxiety

Present Past Obsessive compulsive behavior

Present Past Phobia

Present Past Stress

Present Past Thoughts of suicide

Present Past Suicide attempt(s)

Present Past Self-Injury (e.g. cutting, burning, banging head, etc.)

Present Past Difficulty concentrating

Present Past ADHD

Present Past Low motivation or energy

Present Past Severe mood swings

Present Past Loneliness

Present Past Anorexia

Present Past Bulimia

Present Past Disordered eating

Present Past Anger management

Present Past Family concerns

Present Past Traumatic event

Present Past Physical abuse

Present Past Sexual abuse

Present Past Pornography use

Present Past Gambling

Present Past Recent death or loss

Present Past Legal/Judicial Affairs problem

Present Past Alcohol abuse

Present Past Marijuana use

Present Past Other drugs (e.g. methamphetamine, cocaine, etc.)

Present Past Sexual dysfunction

Present Past Health concern

Present Past Work-related concern

Present Past Identity problem

Present Past Religious or spiritual problem

Present Past Cultural concerns

Present Past Excessive video or online game use

Present Past Other:

What do you see as your top 5 strengths?

1. 2. 3.

4. 5.

What do you do for self-care (i.e. hobbies, interests, etc.)?

Have you experienced any of the following types of abuse or exploitation?

Physical Emotional Sexual Rape/date rape

Parents Marital Status:

Single, Never married

Married (how long? )

Divorced (how long? )

Separated (how long? )

Widowed (how long? )

Do you prefer to speak with a: Male Counselor Female Counselor Either

What is your availability?

Please indicate the service(s) you are interested in exploring during the triage appointment:

Self-help materials Group counseling

Brief problem-solving (1-2 sessions) Referral to other appropriate services

Individual counseling, short (1-4 sessions) Psychiatric assessment and services

Individual counseling (4-12 sessions) Dietitian assessment and services

Long-term individual counseling

What is your Goal for counseling?

At the present time, how well do you feel you are getting along emotionally, mentally and physically?

Very poorly: I can barely manage to deal with things.

Fairly poorly: life is pretty tough for me at times.

So-so: I manage to keep going with some effort.

Pretty well: I have my ups and downs, but I generally manage to do okay.

Very well: much the way I would like to be.

Please use the remaining space on the back of this page to provide any additional information.

INFORMED CONSENT/COUNSELING SERVICES AGREEMENT

CONFIDENTIALITY POLICY

All counseling communications, records, and contacts between you and your counselor will be held in confidence, and will be discussed only with the Director of Counseling Services and supervising team for case management purposes. Exceptions may apply in cases of release, harm, abuse, or court order.

I have read and understand this paragraph (initial)

AUDIO/VISUAL CONSENT

I, , understand that my counselor is involved in internship training and/or a staff counselor at Oasis Counseling Center.

I have read and understand this paragraph (initial)

SUPERVISION AGREEMENT

Oasis Counseling Center is a training facility that employs interns and part time staff counselors. My counselor may meet with a licensed supervisor to ensure best care practices.

I have read and understand this paragraph (initial)

COUNSELING SESSIONS

A counseling session is generally 45-50 minutes and typically scheduled on a weekly basis. If you are unable to keep your appointment, please email or call to cancel or reschedule at least 24 hours prior to the appointment.

The duration of counseling varies. Some individuals require a shorter time to meet their goals while others require counseling over an extended period of time.

I have read and understand this section (initial)