Counseling Services Intake Form

Family History

Mother's Age:

If deceased, how old were you when she died?

Father's Age:

If deceased, how old were you when he died?

Number of Brothers:

Their Ages:

Number of Sisters:

Their Ages:

McMurry Home >> Student Affairs >> Counseling >> Intake/New Appointment

Intake/New Appointment Form

The following intake form is to be filled out by all new clients. You are welcome to print the paper version of this form by choosing one of the versions below (it will take a few moments to load the printable version of the form). Then you may fill out the paper copy, and bring it with you to your first session. For convenience we also provide the option to fill out the form below and submit it to McMurry's Counseling Services Department, however be advised that we cannot guarantee the confidentiality of your information due to the insecure nature of internet forms of communication. If you have any doubts about submitting this form online, please print out the paper version and fill it out instead. If you have any questions, feel free to contact McMurry Counseling Services at (325) 793-4880.

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If you don't have access to Microsoft Word 2000 at home you can download the PDF file that can be viewed by Adobe Acrobat. If you do not have Adobe Acrobat, you may download it FREE here.

Student ID	Date	Intake Counselor

First Name	Middle Initial	Last Name	Maiden Name

Age	Date Of Birth	Gender
		Male		Female

Ethnicity		Relationship Status
White	American Indian	Single	Engaged
Black	Asian Pacific/Islander	Married	Separated
Hispanic	International Student/Country:	Divorced	Widowed

Local/Campus Address	City	State	Zip Code

Local Phone	May We Leave a Message?	E-Mail Address	May We Send a Message?
	Yes No		Yes No

Permanent Address	City	State	Zip Code

Home Phone	May We Leave a Message?
	Yes No

I am currently in my __ year of college	Academic Status	Advisor
1st 2nd 3rd 4th 5+	Fr So Jr Sr

Major 1	Major 2	Cumulative GPA

Minor 1	Minor 2	Number of Credits This Semester

I am currently on academic probation	I have been on academic probation in the past	Hours per week you work in paid employment
Yes No	Yes No

Please indicate who reffered you to the Counseling Center:				Referral Name
Self	Faculty	Residence Life Staff	Other Staff
Friend	Family	Healthcare Provider	Other

Please read the following and check those to which you would respond "yes."

Have you previously been involved in counseling?

Do you currently use alcohol or other non-prescription drugs?

Is there a history of mental health problems in your family?

Have you ever been physically abused?

Have you ever been emotionally abused?

Are your concerns interfering with your academic performance?

Have you ever attempted suicide?

Have you ever been hospitalized for mental health reasons?

Is there a history of alcohol or drug problems in your family?

Have you ever been in legal trouble?

Have you ever been sexually abused or assaulted?

Are you currently taking and prescription medications?

Are your concerns interfering with your ability to stay in school?

Please describe the concerns that you would like to discuss with a counselor:

Under what conditions do your problems get worse/better?	How long has this problem persisted?

Please use the following scale to answer the next three questions	Not at all	Mildly	Moderately	Highly
How serious do you consider your present concern(s)?
How motivated are you to resolve your concern(s)?
How optimistic are you that your concern(s) can be resolved?

I am child number:

in a family of:

Were you adopted or raised with parents other than your natural parents?	Explain:
Yes No

Religious Affiliation
Protestant
Catholic
Jewish
None, but I believe in God
Atheist or Agnostic
Other (please specify)
Do you desire to have your religious values incorporated into the counseling process?	Yes No

Medication
Type/Dosage:	Purpose:



Any Medical Conditions:

Briefly Describe the Following:
Your Mother's Personality	Your Father's Personality	Your Stepparent's Personality

Briefly Describe Your Past and Current Relationship With Your:
Mother:	Father:	Stepmother:	Stepfather:

Feelings (Check all that apply):		Thoughts (Check all that apply):
Helpless	Anxious	Confused	Racing
Depressed	Out of Control	Unintelligent	Obsessive
Shameful	Afraid	Worthless	Distracted
Angry	Numb	Unmotivated	Disorganized
Guilty	Relaxed	Unattractive	Paranoid
Hopeless	Happy	Unlovable	Suicidal
Lonely	Excited	Confident	Sensitive
Sad	Hopeful	Worthwhile	Honest
Stressed	Inferiority Feeling	Homicidal
Unhappy	Mood Shifts
Other:		Other:

Symptoms/Behaviors:
Eating Less	Acting Out Sexually	Marital Relationships
Procrastinating	Acting Aggressively	Socializing
Attempting Suicide	Disorganization	Parent/Child Conflicts
Poor Concentration	Impulsivity	Lack of Ambition/Goals
Crying	Recklessness	Poor Peer Relationships
Withdrawing socially	Irritability	Nightmares
Skipping Classes	Passivity	Worries about body image
Binge Drinking	Drug Use	Spiritual Problems
Injuring Self	Alcohol Use	Dating Concerns
Overeating	Exercising Regularly	Finances
Compulsivity	Being Good to Yourself	Career/Major Choice
Sexual Problems	Other:

Physical Symptoms:		Anything Else You Would Like Us To Know About You:
Insomnia
Tired
Weight gain or loss
Pain
Headaches
Tightness in Chest
Dizziness/Lightheadedness
Numbness/Tingling
Vomiting
Rapid Heart Beat
Dry Mouth
Excessive Sleep
Loss of Memory
Eating Problems
Other:

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