Request for Initial Appointment ~ Counseling Center

Request for Initial Appointment

This information is used only for the purpose of assigning a counselor.

All information will be kept strictly confidential.

First

Middle

Last

Age & Date of Birth

Gender

Ethnicity

Marital Status

Religious Affiliation

Sexual Orientation

Please select the appropriate statement:

Student Classification

If you are a graduate student, please list your major:

Schedule

Counseling appointments are approximately 50 minutes and are free of charge to Lipscomb students.

Note: Appointment times are scheduled Monday – Friday between 8:00 a.m. and 5:00 p.m. Weekly appointments are scheduled for the same day and time each week. We will try to give you an appointment time you prefer, but given the number of people we are trying to accommodate, and the limited number of counseling hours available, we need to know all the times you can be available. You may indicate preferred times with an asterisk (*). Please list ALL the times you can be available.

MWF Mornings

MWF Afternoons

TR Mornings

TR Afternoons

Personal Information

Have you previously been involved in counseling?

If yes, please specify: counselor’s name, agency name, dates, and issues discussed.

Are you in treatment with another counselor at this time?

It is recommended that you only see one counselor at a time. If you are currently seeing a local counselor, you may need to consider either finishing with that counselor and starting with a new UCC counselor, or staying with your current counselor.

If yes, please specify: counselor’s name, agency name, dates, and issues discussed.

Have you ever been hospitalized for any mental health reason?

If yes, please specify: reason, hospital name, and date.

Have you ever had substance abuse treatment?

If yes, please specify: reason, counselor or agency name, and date.

Is there a history of alcohol or drug problems in your family?

Is there a history of mental health problems in your family?

Have you, your spouse, or parents ever served in the military?

If yes, who of the above served?

Are you currently serving, or have you served, as a first responder (police, firefighter, paramedic)?

What medications are you currently taking/prescribed?

What is the dosage or amount of your prescribed medications?

What is the name of the doctor that prescribes your medication?

Additional Information

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

Other information or comments to help us meet your needs:

Lipscomb E-mail Address

We will be in contact with you through your Lipscomb Email address.

Phone

Dorm or Local Address:

If applicable, please indicate who referred you to the Counseling Center

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