Student Health and Counseling Center
P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043 FX: 888-837-2146| www.uaf.edu/chc
UAF SHCC Form for Counseling, Psychological, and Mental Health Medication Evaluation Services
Thank you so much for giving us the opportunity to support you! We appreciate the information you share on this form. It helps your provider know how to contact you as well as get to know you.
Name
*
First Name
Last Name
UA Identification Number
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Gender
Pronouns
Preferred Name
Describe your ethnicity/race
Please describe other aspects of your identity you would like your provider to know about.
What is the best telephone with which to contact you?
*
10 digit phone number include area code
Using this telephone number, do you give permission for UAF SHCC staff to:
*
Yes
No
call you?
leave a voicemail for you?
What is the best email address with which to contact you?
*
example@example.com
Can UAF SHCC Staff use this email address to contact you?
*
Yes
No
What is your current, physical address? If you live on-campus, include the name of your residence hall and room/apt #.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What types of services are you seeking?
Yes
No
Unsure
Individual therapy
Couples therapy
Group therapy
Check-in with a counselor for help or more information about services
Consultation about a concern I have or someone else is experiencing
Help connecting to other resources
Medication Evaluation for Mental Health Concerns
What concerns are you wanting to address in counseling?
What has been helping you cope with or reduce the impact of the concerns you want address?
What do you hope for as a result of accessing and utilizing these services?
Please indicate if you have ever in the past or present:
Yes
No
Unsure
attended outpatient therapy for mental health concerns?
been hospitalized for mental health concerns?
sought treatment for substance abuse?
struggled with thoughts about ending your life?
attempted to end your life?
engaged in self-harming behaviors?
struggled with an eating concern?
experienced difficulty with your vision?
experienced difficulty with your hearing?
experienced difficulty with mobility?
How is your physical health?
Who is your primary care physician?
What is your physician's contact phone number? please enter 10 digit #
phone number
What is your physician's address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any prescription or over-the-counter medications you use currently.
Please list any supplements you use currently.
What is your academic area of study?
Please describe how you are feeling about your academic progress.
Please indicate if you are working currently and what kind of work you perform.
Please describe any legal concerns you have experienced in the past or present.
Please describe any hobbies, special interests, or strengths you have.
If you have other information you would like to share with your counselor, please feel free to expand upon it.
How did you learn about UAF SHCC services? We are very happy you contacted us!
Date of signature
*
-
Month
-
Day
Year
Date
Signature
*
Submit
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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