University Wellness Center - CAPS
Initial Consultation Form First Name:
Middle:
Date of Birth:
Current Age:
Current Academic Status:
☐ Freshman
Last:
Student ID #:
☐ Sophomore
☐ Junior
☐ Senior
☐ Other:
How many classes are you currently enrolled in?
Preferred Phone #:
Permission to
Contact:
Preferred
Phone:
Other Phone #:
☐ YES
Are you currently in crisis?
☐ NO
Other
Phone:
E-mail:
☐ YES
E-mail:
☐ YES
☐ NO
☐ YES
(If yes, please include a description in the box below) ☐ NO
☐ NO
Briefly describe why you have come to the University Wellness Center today. What issues or concerns do you have? Who referred you to the Wellness Center?
☐ Self ☐ Family
☐
☐ Medical
Residential Life
Have you previously used our services?
☐ Faculty:
☐ Dean of Students
☐ YES
☐ Friends:
☐ Other:
☐ NO
If yes, when:
Have you had prior counseling or mental health services elsewhere?
☐ YES
If yes, # of sessions/months:
With:
When:
Where:
Are you currently prescribed
any medications? If so, what:
Do you have any serious
medical conditions? If so, what:
Think back over the last month. How many times have you
had: five or more drinks* in a row (for males) OR four or
more drinks in a row (for females)?
(* A drink is a bottle of beer, a glass of wine, a wine cooler, a shot glass of
liquor, or a mixed drink.)
☐ None
☐ 1 to 2 times
☐ 3 to 5 times
☐ 6 to 9 times
☐ 10 or more times
☐ NO
Think back over the last month. How many times have you
used other substances (e.g., marijuana, cocaine, MDMA,
methamphetamines)?
☐ None
☐ 1 to 2 times
☐ 3 to 5 times
☐ 6 to 9 times
☐ 10 or more
times
Think back over the last two weeks. On average, how many
hours of sleep do you think you have been getting per night?
☐ 0-3 hours
☐ 4-5 hours
☐ 5-7 hours
☐ 7-9 hours
☐ 10 or more
hours
Please indicate how many times and the last time you had each of the following experiences:
How Many Times
The Last Time
Been hospitalized for mental health
concerns:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Purposely injured yourself without
suicidal intent:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Seriously considered attempting
suicide:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Made a suicide attempt:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Considered causing serious physical
injury to another person:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Intentionally caused serious physical
injury to another person:
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago
Someone had sexual contact with you
without your consent (e.g., you were
afraid to stop what was happening,
passed out, drugged, drunk,
incapacitated, asleep, threatened,
physically forced):
☐ Never
☐ 1 time
☐ 2-3 times
☐ 4-5 times
☐ More than 5 times
☐ Never
☐ Within the last 2 weeks
☐ Within the last month
☐ Within the last year
☐ Within the last 1-5 years
☐ More than 5 years ago