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Intake/New Appointment Form


The following intake form is to be filled out by all new clients. You are welcome to print the paper version of this form by choosing one of the versions below (it will take a few moments to load the printable version of the form). Then you may fill out the paper copy, and bring it with you to your first session. For convenience we also provide the option to fill out the form below and submit it to McMurry's Counseling Services Department, however be advised that we cannot guarantee the confidentiality of your information due to the insecure nature of internet forms of communication. If you have any doubts about submitting this form online, please print out the paper version and fill it out instead. If you have any questions, feel free to contact McMurry Counseling Services at (325) 793-4881.

Download and Print the form here.
If you don't have access to Microsoft Word 2000 at home you can download the PDF file that can be viewed by Adobe Acrobat. If you do not have Adobe Acrobat, you may download it FREE here.

Best Available Time:

Next Available Time:

Next Available Time:

Student ID Date Have You Received Counseling at McM?
Yes   No

First Name Middle Initial Last Name Maiden Name

Age Date Of Birth Gender
Male Female

Ethnicity Relationship Status
White Native Indian Single Engaged
Black Asian Pacific/Islander Married Separated
Hispanic International Student/Country: Divorced Widowed

Local/Campus Address City State Zip Code

Local Phone May We Leave a Message? E-Mail Address May We Send a Message?
Yes No
Yes No

Permanent Address City State Zip Code

Home Phone May We Leave a Message?
Yes No

I am currently in my __ year of college Academic Status Advisor
1st 2nd 3rd 4th 5+ Fr So Jr Sr

Major 1 Major 2 Cumulative GPA

Minor 1 Minor 2 Number of Credits This Semester

I am currently on
academic probation
I have been on academic
probation in the past
Hours per week you work in
paid employment
Yes No Yes No

Please indicate who reffered you to the Counseling Center:
Referral Name
Self Faculty Residence Life Staff Other Staff
Friend Family Healthcare Provider Other

Please read the following and check those to which you would respond "yes."
Have you previously been involved in counseling?
Do you currently use alcohol or other non-prescription drugs?
Is there a history of mental health problems in your family?
Have you ever been physically abused?
Have you ever been emotionally abused?
Are your concerns interfering with your academic performance?
Have you ever attempted suicide?
Have you ever been hospitalized for mental health reasons?
Is there a history of alcohol or drug problems in your family?
Have you ever been in legal trouble?
Have you ever been sexually abused or assaulted?
Are you currently taking and prescription medications?
Are your concerns interfering with your ability to stay in school?

Please describe the concerns that you would like to discuss with a counselor:

Under what conditions do your
problems get worse/better?
How long has this problem persisted?

Please use the following scale to
answer the next three questions
Not
at all
Mildly
Moderately
Highly
How serious do you consider your present concern(s)?
How motivated are you to resolve your concern(s)?
How optimistic are you that your concern(s) can be resolved?

Family History
Mother's Age: If deceased, how old were you when she died? 
Father's Age: If deceased, how old were you when he died?   
Number of Brothers: Their Ages:
Number of Sisters: Their Ages:
I am child number: in a family of:

Were you adopted or raised with parents
other than your natural parents?
Explain:
Yes No

Religious Affiliation
Protestant
Catholic
Jewish
None, but I believe in God
Atheist or Agnostic
Other (please specify)
Do you desire to have your religious values
incorporated into the counseling process?
Yes No

Medication
Type/Dosage: Purpose:
Any Medical Conditions:

Briefly Describe the Following:
Your Mother's Personality
Your Father's Personality
Your Stepparent's Personality

Briefly Describe Your Past and Current Relationship With Your:
Mother:
Father:
Stepmother:
Stepfather:

Feelings (Check all that apply): Thoughts (Check all that apply):
Helpless Anxious Confused Racing
Depressed Out of Control Unintelligent Obsessive
Shameful Afraid Worthless Distracted
Angry Numb Unmotivated Disorganized
Guilty Relaxed Unattractive Paranoid
Hopeless Happy Unlovable Suicidal
Lonely Excited Confident Sensitive
Sad Hopeful Worthwhile Honest
Stressed Inferiority Feeling Homicidal    
Unhappy Mood Shifts        
Other: Other:

<>Symptoms/Behaviors:<>
Eating Less Acting Out Sexually Marital Relationships
Procrastinating Acting Aggressively Socializing
Attempting Suicide Disorganization Parent/Child Conflicts
Poor Concentration Impulsivity Lack of Ambition/Goals
Crying Recklessness Poor Peer Relationships
Withdrawing socially Irritability Nightmares
Skipping Classes Passivity Worries about body image
Binge Drinking Drug Use Spiritual Problems
Injuring Self Alcohol Use Dating Concerns
Overeating Exercising Regularly Finances
Compulsivity Being Good to Yourself Career/Major Choice
Sexual Problems Other:

Physical Symptoms: Anything Else You Would Like Us To Know About You:
Insomnia
Tired
Weight gain or loss
Pain
Headaches
Tightness in Chest
Dizziness/Lightheadedness
Numbness/Tingling
Vomiting
Rapid Heart Beat
Dry Mouth
Excessive Sleep
Loss of Memory
Eating Problems
Other:



Jesse Potter, M.Ed, LPC, LCDC
Coordinator of Counseling Services
Disability Services Coordinator

President Resident Hall South
Office: (325) 793-4881
Fax:    (325) 793-4879

Office Hours:
Monday:  8am-2pm
Tuesday: 8am-2pm
Wednesday:  8am-2:30pm
Thursday: 8am-3pm
Friday:   10am-3pm

1 McMurry University, #716
Abilene, TX 79697

potter.jesse@mcm.edu

Counseling Staff

Counseling Office

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