SG Mental Health Intake Form (UTHRIVE)

SG Mental Health Counseling (UTHRIVE)

Mental Health Inquiry Questionnaire
Full Name:

First NameLast Name
DOB

MonthDayYear
Date
Patient Phone:

Area CodePhone Number
E-mail
What is your age?
Name of University/College:
Reason for Service:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mental Health & Well-Being
What mental health concerns are you currently experiencing? (Check all that apply):

StressAnxietyDepressionRelationship IssuesAcademic StressAdjustment to College LifeSleep ProblemsSubstance UseOther
Have you sought mental health services before?

YesNo
What type of support are you looking for? (Check all that apply):

Individual CounselingGroup CounselingWorkshops/SeminarsPeer Support Check InWorkshops/SeminarsCrisis InterventionOther
How would you prefer to engage in services?

In-PersonVirtualNo PreferenceOther
Preferred Days for Appointments (Check all that apply):

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Time of Day for Appointments (Check all that apply):

MorningAfternoonEvening
Do you reside in Southern Scholarship Foundation Housing?

YesNo
Message / Notes
Is there anything else you would like for us to know about your mental health concerns or needs?: *
Logged:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

SG Mental Health Counseling (UTHRIVE)