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The mission of Eastfield College is to provide excellence in teaching and learning.

Eastfield Counseling Services
Initial Counseling Consultation Form


Gender:
Sexual Orientation:

                            May we leave a msg?
                               May we leave a msg?



Referred by:

Race/Ethnicity:

What is your country of origin?
Are you an international student?

Relationship Status:

With whom do you live with? (Check all that apply):

Current Academic Status:
Did you transfer from another campus/institution to the school?
What's your current GPA: Major:
Are you the first generation in your family to attend college?

Do you participate on an athletic team that competes with other colleges or universities?
What is the average number of hours you work per week during the school year (paid employment only)?

How would you describe your financial situation now? Sometimes stressful

Have you ever been enlisted in any branch of the US military (active duty, veteran, national guard, reserves)?

Did your military experiences include any traumatic or highly stressful experiences which continue to bother you?


Are you currently receiving (or previously engaged in) psychiatric services or counseling elsewhere?
Are you currently taking prescribed psychiatric medication (antidepressants or others)?

Present state of physical health:

Instructions: Please indicate if and when you have had the following experiences Never Prior to College After starting college Both
1. Attended counseling for mental health concerns
2. Taken a prescribed medication for mental health concerns
3. Been hospitalized for mental health concerns
4. Felt the need to reduce your alcohol or drug use
5. Others have expressed concern about your alcohol or drug use
6. Received treatment for alcohol or drug use
7. Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, hair pulling, etc.)
8. Seriously considered attempting suicide
9. Made a suicide attempt
10. Seriously considered injuring another person
11. Intentionally injured another person
12. Had unwanted sexual contact(s) or experience(s)
13. Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure)

14. Have you experienced, witnessed, or learned of a traumatic event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of yourself or others?
15. If you selected, “Yes” for the previous question, did the traumatic event(s) cause you to feel intense fear, helplessness, or horror?

17. Think back over the last two weeks. How many times have you had: five or more drinks* in a row (for males) OR four or more drinks* in a row (for females)? (*A drink is a bottle of beer, a glass of wine, a wine cooler, a shot glass of liquor, or a mixed drink.)
18. Do you have a diagnosed and documented disability? (Check all that apply)



19. Please indicate how much you agree with this statement: “I get the emotional help and support I need from my family.”

20. Please indicate how much you agree with this statement: “I get the emotional help and support I need from my social network (e.g., friends & acquaintances).”