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New Client Intake Form
New Client Intake Form
Full Name
*
*
Are you a student?
*
Yes
No
Student ID
*
*
Date of Birth
*
Gender
Woman
Man
Transgender
Self-Identify
Relationship Status
Single
Serious dating or committed relationship
Domestic Partnership
Married
Separated
Divorced
Widowed
Address
*
City
*
State
*
Zip Code
*
Phone
*
*
May we leave a message at this phone number?
May we leave a message at this phone number?
No
May we leave a message at this phone number?
Yes
CSI Email
*
*
*
May we contact you at this email address?
May we contact you at this email address?
No
May we contact you at this email address?
Yes
What is your major?
*
Number of credits taking this semester
*
*
How many semesters have you attended CSI?
Less than 1 semester
1 semester
2 semesters
More than 2 semesters
Average # of hours working each week this semester
*
*
How I learned about CSI Counseling Services
Friend
Instructor
CSI Website
Other
Reasons for Seeking Counseling
Addiction
Anxiety
Depression
Financial Concerns
Grief
Lack of motivation
Relationship Struggles
Stress
Test Anxiety
Trauma
Other
*
Emergency Contact Information
Full Name
*
Phone
*
Relationship
Spouse
Partner
Mother
Father
Brother
Sister
Friend
Other
Informed Consent for Treatment
Please select "I Agree" in the box below to indicate that you have read and agree to the terms above
*
I Agree
