-1(office use only）Phone intake In person Walk-in ＃ Initials CONFIDENTIAL TUJ Counseling Office Intake Form The following information will help us to serve you better and save time in your first session. Please fill out this form and slip underneath the door if a counselor is not available. 下記の情報は、より良いサービスの提供と初回の面談にて時間を有効に使うのに役立ちますのでご協力下さい。カウンセラー不在の場合、記入後ドアの下に入れて下さい。 Date(日付): Section I: IDENTIFYING INFORMATION 個人情報 Name（氏名） last（姓） first（名） Ethnicity (エスニシティ):African-American Arab Current Address（現住所）: Home phone: Cell phone: E-mail address: Emergency Contact（緊急連絡先）:Name Program： AEP Asian-American Caucasian OK to call and identify OK to call and identify Chinese Yes Yes No No Undergraduate (Bridge / Japan Admit / Study Abroad) Multiethnic Other Law MBA Yes Yes Yes 日本語 Who referred you to the Counseling Office? Self Orientation Flyer □ No English Faculty OSS Family AAC Friend Other Staff: Referral Name: Other 相談内容：当てはまるものを全てチェックしてください。 □Abuse/Assault(虐待・暴力) □Academic concern(学業) □Anxiety/worry(不安・心配) □Attention problem(注意力不足) □Family ) どなたからカウンセリングオフィスを紹介されましたか？ Brochure Concerns: Please check all that apply. Problems(摂食問題) No No No TESOL Other Did you transfer to TUJ? 編入生？□ Yes (specify: Language Preference(希望する言語): issues(家族問題) □Adjusting □Pregnancy/abortion(妊娠・中絶) □Relationship Skills (勉強の仕方) to college(学校への適応) □Career Concern(就職) □Finances(お金) □Goal □Homesick(ホームシック) □Identity(アイデンティティ) □Learning □Stress(ストレス) □Study Korean Other Year in School (学年)： Major(主専攻): Referral Type Japanese Male OK to leave message OK to leave message OK to receive E-mail ) Contact (Relationship: Starting Date (入学時期): □Eating middle Gender（性別）：Female Age（年齢） Date of Birth (生年月日) (人間関係) □Suicidal □Alcohol/drugs(飲酒・薬物) □Anger (怒り) □Decision Making(意思決定) setting/attaining(目標設定・達成) disability (学習障害) □Depression(憂鬱な気分) □Health concerns(健康) □Manic(躁病) □Panic(パニック) □Religion(宗教) □Self-esteem(自尊心) □Sexuality(性) □Sleeping thoughts(自殺企図) problem(睡眠) □Other（その他） Please describe in details: How long has this been a problem? (e.g., days, weeks, months, etc.) この問題に悩み始めてどの位たちますか？(例：日、週、月単位で) In the last 2 weeks, have you been afraid you might hurt yourself or someone else? □ Yes (はい) □ No (いいえ) 過去 2 週間のうち、自分もしくは誰かに危害を加えるのではないかと怖くなったことはありますか？ Please check the services you are interested in: (check all that apply) 受けてみたいと思うサービスを選んでください。（当てはまるもの全て） □ Academic assistance 修学支援 □ One- or Two-session problem solving 1-2 回の面談での問題解決 □ Individual short-term counseling (12 or fewer sessions) 短期個人カウンセリング（12 回以下） □ Individual counseling (long-term) 長期個人カウンセリング □ Group counseling グループカウンセリング Please circle specific times you are available for appointments: 予約可能な時間にまるをしてください。 Monday Tuesday Wednesday Thursday Friday 10am 10am 10am 10am 10am 11am 11am 11am 11am 11am 12pm 12pm 12pm 12pm 12pm 1pm 1pm 1pm 1pm 1pm 2pm 2pm 2pm 2pm 2pm 3pm 3pm 3pm 3pm 3pm 4pm 4pm 4pm 4pm 4pm Rev. 1/09 -2(office use only）Phone intake In person Walk-in ＃ Initials CONFIDENTIAL Section I: IDENTIFYING INFORMATION (Cont’d) 個人情報（続き） Residence 住まい □ □ □ □ □ Living situation Apartment アパート・マンション House 家 TUJ Dorm TUJ の寮 TUJ housing TUJ 関係のハウジング Other その他 □ □ □ □ 生活状況 Credits this term 今学期の履修単位 Alone 一人暮らし Roommate(s) ルームメイト Parents/siblings 親・兄弟姉妹 Partner/Spouse パートナー・配偶者 MARITAL STATUS 婚姻および親しい関係 □ Single 独身 □ Dating 交際中 □ Married/Partnered 既婚・パートナーがいる □ Separated 別居中 □ Divorced 離婚 □ Other その他 1-5 6-10 11-15 16-20 □ □ □ □ □ □ Over 20 Leave of Absence 休学中仕事の有無 Are you employed? □ Yes Where どこで □ No Hours/wk 週の就業時間 Section II: HEALTH AND FAMILY INFORMATION 健康と家族について Are you currently (or within the past year) under the care of a medical doctor? □ Yes はい □ No いいえ現在（もしくは過去 1 年以内に）お医者さんにかかっていますか？ If yes, for what condition：はいの場合、どのような症状： Do you have any other significant medical conditions? □ 他に深刻な病状がありますか？ Yes はい □ No いいえ If yes, for what condition：はいの場合、どのような病状： Are you currently taking any medications, herbs or Chinese herbs? □ Yes はい □ No いいえ現在、薬やハーブおよび漢方薬を飲んでいますか？ Name of medication/herb(s): 薬、ハーブおよび漢方薬の名前 Who prescribed it for you: 誰が処方しましたか Do you have a disability? If yes, please describe: 障害がありますか？ □ Yes はい □ No いいえはいの場合、説明して下さい Have you had previous counseling or psychotherapy? カウンセリングやサイコセラピーの経験がありますか？ Where どこで Name of counselor カウンセラーの名前 When & How long いつ＆どの位 □ Yes はい □ No いいえ Does any member of your family suffer from alcoholism, depression, anxiety, or anything that can be considered an emotional or mental difficulty? 家族の中でアルコール依存症、うつ、不安症やその他の心理的な問題を抱えている人がいますか？ □ Yes はい □ No いいえ If yes, please describe: はいの場合、説明して下さい Do you use alcohol or drug to (check all that apply): □ Social?付き合いで □ Manage Stress?ストレス発散 □ To relax?リラックスしたいアルコールやドラッグを使うことがある（当てはまるもの全て）：□ To change mood?気分転換したい □ For sleep?よく眠りたい How often do you use alcohol or drug? アルコールやドラッグの使用頻度： □ More than once a week 週 1 回以上 Æ Do you feel that you need the substances to get by? □ Once a week or less 週 1 回かそれ以下 □ Do not use 使わない生きる為にこうした薬物が必要？□Yes はい□No いいえ Have you been in any abusive relationships? これまでに虐待的な関係にいたことがありますか？ If yes, please check following:はいの場合、下記をチェックしてください。 Type of Abuse(虐待の種類) Type of Abuser(加害者の種類) □ Physical abuse 身体的虐待 □ Parent(s) 親 □ Verbal abuse 言葉の虐待 □ Brother/Sister 兄弟姉妹 □ Emotional abuse 感情的虐待 □ Partner 恋人・パートナー □ Sexual abuse 性的虐待 □ Friend(s) 友人 □ Yes はい □ □ □ □ No いいえ Professor 教授 Neighbor 隣人 Other その他 □ Neglect ネグレクト When & How long? いつ & どの位？ Family Information ご家族について Relationship 関係 Mother 母親 Age 年齢 Supportive？頼りにできる？ Y N Relationship 関係 Spouse 配偶者 Age 年齢 Supportive？頼りにできる？ Y N Father 父親 Y N Children 子供 Y N Brother(s) 兄弟 Y N Grandmother 祖母 Y N Sister(s) 姉妹 Y N Grandfather 祖父 Y N If parents are separated/divorced, how old were you then? 両親が別居・離婚の場合、あなたは何歳でしたか？ -3(office use only）Phone intake In person Walk-in Initials ＃ CONFIDENTIAL Section III: DESCRIPTION OF PRESENTING PROBLEMS 今抱えている悩みについて Please use the following scale to answer the next three questions: 次の３つの質問に対して隣の基準からランク付けしてください。 1 2 Not at all 全然 Mildly 少し 1. How serious you estimate is your concern(s) at this time? 3 Moderately 中位 4 Highly 非常に □ □ □ □ □ □ □ □ □ □ □ □ 現在あなたの悩みはどのくらい深刻だと思いますか？ 2. How motivated are you to resolve your concern(s)? この悩みを解決するのにどのくらいやる気がありますか？ 3. How optimistic are you that your concern(s) can be resolved? あなたの悩みが解決されるのをどの程度楽観的に捉えていますか？ For your current concern, please take a look at the following page in which you will find a list of problems that people commonly face. The list surveys family, academic, social, spiritual, and other problems of everyday life. Read the list carefully and check all the item(s) that are causing you the most trouble at this time. あなたが現在抱えている問題について、次ページの「気がかりなことのリスト」を参照して下さい。この一覧は、一般によく聞かれる悩みを家族、学業、社交、友達といった日常生活の場面別にまとめたものです。これらの項目によく目を通して頂き、現在あなたが困っている、心配しているもの全てにチェックをつけて下さい。 Please estimate how much your concerns are affecting the following areas of your life: 今の悩みがあなたの生活の下記の場面にどの位影響していると思いますか？ Academic 学業面 Social 社交 □ No interference 全く影響なし □ No interference 全く影響なし □ Mild interference 少し影響あり □ Mild interference 少し影響あり □ Moderate interference ある程度影響あり □ Moderate interference ある程度影響あり □ Severe interference かなり影響あり □ Severe interference かなり影響あり Anything else you would like us to know about you: その他私たちに知っておいてほしいと思うことを書いてください。 -4(office use only）Phone intake In person Walk-in Initials ＃ CONFIDENTIAL Concern Checklist: Anxiety Sadness Fears Substance Use □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Bad dreams/Nightmares Being overly excited Difficulty relaxing Feeling nervous Racing thoughts Afraid of hurting self Difficulty concentrating Feeling overly emotional Feeling depressed Suicidal thoughts/behaviors Fear of death Fear of failure Fear of future Fear of people Irrational fears Difficulty quitting addiction Drinking too much alcohol Fear if overdosing Smoking too many cigarettes Using drugs Parents Finances Feelings Spirituality □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Difficulty talking with parents Parents constantly arguing Parents being too strict Parents interfering with life Parents Separated/Divorced Poor relationship with parents Can’t make ends meet Can’t decide on career Spending money foolishly Unable to find job Worried about finding job Worries about money Feeling anxious Feeing guilty Feeling inferior Feeling lonely Feeling no one likes me Feeling sad Afraid God will punish me Confusion about God Feeling unaccepted by God Failure with God Feeling abandoned by God Inability to get to church Anger Friends Health Self-Esteem □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Difficulty loosing temper Fear that I might hurt someone Feeling jealous Getting into arguments Hurting other’s feelings Inability to express anger Upset about past hurts Death of close friend Difficulty getting close w/ others Friend emotionally upset Friend committing suicide Friend with serious illness Missing good friend(s) Picking the wrong friends Anorexia Bulimia Headaches Lack of Energy Lack of Sleep Racing heart Stomachache/ulcer Being overweight Being underweight Being noticed for physical appearance Eating too much Feeling unattractive Hating Self Poor eating habits Social Situations Sexuality School Guilt □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Awkward meeting new people Being criticized by others Being left out of things Critical of others Difficulty making friends Having a bad attitude Having few hobbies Having strong opinions Having little/no opinions Lacking self-confidence Lack of interest in activities Uncomfortable in situations Wish people liked me better Concern about sexual orientation Dating issues Difficulties with sexual thoughts Difficulties getting dates Difficulties with sexual behavior End of relationship Involved in bad relationship Memories of past sexual abuse No sexual thoughts/behaviors Questions about sex Uncomfortable with other sex Sexually underdeveloped Wondering about marriage Difficulty with professor Difficulties with reading Difficulties finding right major Feeling out of place in school Getting low/failing grades Language problem in school Missing school due to illness Not enough money for school Overloaded with work Poor memory for work Poor study habits Unable to concentrate on work Worries about grades Family Other Other continued □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Death of family member Difficulty with brother/sister Family member with illness Family member loosing job Feeling homesick Poor relationship with family Acting strangely Compulsive behaviors Difficulties with reality Family history of mental illness Feeling strange Gender confusion Hearing voices Involved in abusive situation Little or no emotion Loosing portions of time Obsessive thoughts Self-harming behaviors Being careless Cheating on schoolwork Feeling ashamed of something Getting into trouble Giving into temptation Involved in sexual relationship Lacking self-control Not being honest with others Not taking things seriously Stealing from others Unable to stop bad habit Use of pornography Unexpected Pregnancy OTHER (Please specify):