hanover.edu
Counseling Services
Counseling Services Student Clients
Academic Term:
# Last Name First Name Intake Questionnaire Initial Assessment Counselor
No student clients assigned.
[Remove]
[Discharge Client]
Disclosure Authorization
Intake Questionnaire
Initial Assessment
Counselor:
Personal InformationResponse
Date of birth
Pertinent details
Academics and Student LifeResponse
Current GPA
What is your declared or intended major?
Who is your academic advisor?
Are you on academic probation?
If you are an international student, what country are you from?
If you are a student athlete, what sport(s) do you participate in?
If you are involved in Greek Life, which organization are you a member of?
Please list any other campus involvement that is important to you.
Did your parents or grandparents complete college?
Social SupportsResponse
Please describe your relationship with your family.
Please share a little bit about your important relationships or social supports.
Treatment and Medical InformationResponse
Have you participated in counseling before?
If so, what concerns were you addressing?
If so, what was helpful about your experience with counseling? What would have been more helpful?
How would you describe your overall health and wellness? Consider things like sleep, nutrition, and physical activity.
Please list any medications which you are currently taking and why it is prescribed.
CancernsResponse
Depressed Mood
Anxiousness/Worry
Family
Friends/Peers
Sex
Academics
Substance Use
Legal Issues
Finances
Food
Anger
Suicidal Thoughts
Body/Physical Appearance
Counseling ServicesResponse
Briefly describe why have you have chosen to seek counseling services.
Have you been to counseling services before? If so, who did you see?
How did you learn of our services and/or who referred you to us (source of referral)?
What would you like to see improve as a result of participating in Counseling Services?
Heath ServicesResponse
Authorize Counseling Services to share my mental health information with Health Services as pertinent to my treatment.
Student LifeResponse
Authorize Counseling Services to share my mental health information with Student Life professionals as pertinent to my treatment.
Student Initial Assessment:
Date:
Duration/Status:
Referred by:
Presenting concern:
Primary concern:
-
Secondary concern:
-
Student demeanor:
Suicidal/Homicidal ideation:
Student wellbeing:
Student cultural/spiritual factors:
Student marital/family history:
Student social history:
Student abuse history:
Student medical history:
Student mental health history:
Student medications:
Summary:
Treatment plan:
Counselor
Date
Duration
Referred by
Presenting concerns
Primary concern
Primary concern other
Secondary concern
Secondary concern other
Student demeanor
Student suicidal/homicidal ideation
Student wellbeing
Student cultural/spiritual factors
Student family history
Student social history
Student abuse history
Student medical history
Student mental health
Student medications
Summary
Treatment plan
Student Session:
Session Name:
Date:
Duration/Status:
Concern:
Assessment of S/I or H/I:
Summary:
Follow-up:
Name
Date
Duration
Concern
Assessment
Summary
Follow-up
Counselor
Student Notes:
#NameDateCounselorOptions
Student Documents:
#NameUploadedOptions
Student Sessions:
#NameDateCounselorDuration