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Counseling Services
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Intake Questionnaire

This Intake Questionnaire form must be submitted every academic school year prior to meeting with a counselor. It is important that you review the Client Rights, Client Responsibilites & Confidentiality sections carefully before submitting the form.

If you are currently experiencing thoughts of harm to self or others, please contact Campus Safety at 812-866-7999 or 911, who will connect you with resources immediately. You can also reach a qualified Crisis Counselor by dialing 988.

Client Rights:

You have a right to request a copy of records generated by our office. Typically, you will be asked to meet with your counselor to review the records before they are released to you.

  • You have the right to be treated with dignity and respect without regard to your race, color, religion, national origin, gender, age, sexual orientation, or disability.
  • You have the right to have your counselor explain the way in which your confidential mental health information will be handled and the limitations of confidentiality.
  • You have the right to request a specific counselor, request a different counselor than the one assigned to you, or ask for a second opinion.
  • You have the right to receive an appropriate referral for community mental health services if you request one or if your needs exceed what we are able to provide you.
  • You have the right to work collaboratively with your counselor in establishing treatment goals.
  • You have the right to ask questions about your counselor's qualifications, credentials, and theoretical orientation, as well as any counseling and testing techniques/procedures utilized.
  • You have the right to refuse or terminate treatment.
  • You have the right to review with your counselor the records in your personal file maintained by Counseling Services, including diagnosis and test results.

Client Responsibilities:

  • You should make every effort to arrive on time for appointments.
  • You should notify Counseling Services if you are unable to keep a scheduled appointment. Clients who consistently miss appointments without notification may have those services terminated or restricted.
  • You are expected to arrive for appointments without being under the influence of drugs or alcohol.

Client Confidentiality:

Records maintained by Counseling Services are considered medical records and protected health information. As such, these electronic medical records are kept separate from all other student records. This means that what you tell or otherwise share with your counselor and the Counseling Services staff will remain confidential. Consultation with individuals or organizations outside Counseling Services, including faculty, family, or friends require your written consent. There are, however, some exceptions and limitations to confidentiality as required by law.

The most common limitations of confidentiality in counseling include imminent danger to self, duty to warn another person who may in danger, and suspected abuse or neglect of a child or elder.

Intake Questionnaire Form

It's ok if you choose not to answer each question. Providing information on this form will help your counselor get to know you better.

Personal Information
Date of birth:
Please share any pertinent information related to your cultural identities.
This might include race, ethnicity, sexual orientation, gender identity, pronouns, or other aspects of your identity that are important to you:
Academics and Student Life
Current current grade point average (GPA):
Declared or intended major:
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 Supports
Please describe your relationship with your family:
Please share a little bit about your important relationships or social supports:
Treatment and Medical Information
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:
Concerns

Please rank your degree of concern about the following areas. 0 = no concern, 10 = very concerned

Depressed Mood:
Anxiousness/Worry:
Family:
Friends/Peers:
Sex:
Academics:
Substance Use:
Legal Issues:
Finances:
Food:
Anger:
Suicidal Thoughts:
Body/Physical Appearance:
Counseling Services
Briefly describe why have you have chosen to seek counseling services:
Have you been to counseling services before? If so, who did you see?
Do you have an initial appointment counselor preference?
Please indicate the days and times you are available for your initial appointment with a counselor:
MonTueWedThuFri
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
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?

By submitting this form, you confirm that you have read and understand the Client Rights, Client Responsibilities, and Client Confidentiality statements.

You also affirm that you have reviewed the Privacy Policy and Authorization to Disclose Limited Mental Health Information, which provides a detailed description of the potential uses and disclosures of your protected health information and rights on these matters.