CUSOM Behavioral Health
Date: __________________
Intake Form
** Please use an ink pen to complete this form**
Gender:
Date of Birth:
Age:
______/_______/_______
________
First Name:
 Female
Middle Name:
Last Name:
Preferred Name:
-
Local: (Room extension or off campus number)
Home (permanent home number): (
)
-
E-mail:
May we
mention CS?
)
May we leave
a message?
Ways to reach you:
Is it okay to
contact you
here?
Today’s Date:
CU Student ID#:
Cell: (
 Male
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
NOTE: EMAIL IS NOT CONSIDERED A CONFIDENTIAL FORM OF COMMUNICATION
Campus mail box number:
Off-campus address, if applicable:
Permanent address:
Street:
City:
State:
Zip:
Permanent address phone number: ________________________________________
Emergency Contact Information: Who can we contact in case of an emergency?
Person’s Name: _________________________________
Relationship to You: _____________________ _
Phone Number(s): _______________________________
Who referred you to Counseling Services?
(check all that apply)
 Self
 Friends
 Parents/ Relative
 Partner/Spouse
 Boyfriend/Girlfriend
 Counseling Services’
 Online Screening (i.e.
ULifeline, halfofus.com)
 Student Health Services
 Other Medical Professional
 Judicial Offices at CU
 Residence Life staff (RA, RD,
Resident Chaplain)
 Academic Adviser
 Faculty:________________
 Staff:__________________
 Other:_________________
Have you ever served in
a branch of the US Military?
 Yes  No
Did your service include
a combat tour of duty?
 Yes
 No
What is (are) the main
reason(s) for your meeting
today? (Check all that apply.)
 Personal / Psychological
 Alcohol / Drug Concerns
 Academic
 Interested in:  One- or Twosession problem-solving 
Medication Services  Group
Counseling
 Other:
Are you registered with Student Success
(CU’s office for disability services),
as having a documented and diagnosed disability?
Have you had previous counseling or psychotherapy?
Yes  No 
 Yes  No
Where?
If you selected “yes” for the previous question, please indicate
which category of disability you are registered for:
(check all that apply)









________________________________________________
When?
Attention Deficit/ Hyperactivity Disorders
Neurological Disorders
Deaf or Hard of Hearing
Physical/ Health Related Disorders
Learning Disorders
Psychological Disorder/ Condition
Mobility Impairments
Visual Impairments
Other __________________________________
________________________________________________
Why?
_______________________________________________
Are you presently receiving counseling from some
person/agency other than this service?
Please describe how your disability impacts
your performance as a student.
Yes  No 
Where?
_____________________________________________
Are you currently under the care of a medical doctor?
Please list any medical conditions or health problems
(i.e., chronic pain, headaches, diabetes…)
 Yes  No
If yes, name of Physician:
_______________________________
Name of Physician’s Practice:
_____________________________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Religious or Spiritual preference:  Christian - Catholic  Christian - Protestant/Non-Catholic  Agnostic  Atheist
 Buddhist  Hindu  Jewish  Muslim  No preference  Prefer not to answer
 Other: ____________________
To what extent does your religious or spiritual preference play an important role in your life?
 Very Important  Important  Neutral  Unimportant  Very Unimportant
Do you have children?  Yes
 No
If yes, how many?  1  2  3 or more
Ages? ____________________________
What is your relationship status?
 Single
 Dating
 Committed Relationship
 Engaged
 Married/ Partnered
 Separated
 Divorced
 Widowed
 Other _____________________
 Decline to Respond
Does your family have a
history of: (check all that
apply)










None of these
Psychiatric Hospitalization
Alcoholism
Drug Use
Abuse
Depression
Bipolar Disorder
Eating Disorders
Prison
Other:











Please check any past, present, or impending
problems in your family: (check all that apply)
Deaths
Divorce
Frequent Relocations
Debilitating Injuries/ Disabilities
Serious Illness
Psychiatric Disorder/Mental Illness
Physical/ Sexual Abuse
Domestic Violence
Financial Crisis/ Unemployment
Legal Problems
Attempted/ Completed Suicide
Other _____________________
I, the undersigned, understand the information provided in this document is confidential and will be discussed
with me during my initial appointment.
_________________________________________________________
Print Name
Date
_________________________________________________________
Signature
Date