Tufts University Counseling and Mental Health Service

CMHS Confidential Student Information Form

Date: ______Tufts ID#: ______Health Insurance Information: ______

Name: ______Preferred Name (If different):______

Date of Birth: ______Age: ______Phone: ______

Email: ______Please note: Your clinician will contact you through the secure portal.

Local address: ______

Permanent Address/Phone: ______

Emergency contact information: (Name, Relationship, Address & Phone) ______

Month and year you entered Tufts: ______Current Class Year: ______

Major/Area of Study: ______

Gender Identification: ______Pronouns: ______CMHS Confidential Student Information Form

Current Relationship/Marital Status: ______

How do you usually describe your race and/or ethnicity? How do you usually describe your sexual orientation?

o White or Caucasian, non-Hispanic, Non-Arab o Lesbian o African American/Black, non-Hispanic o Gay o Hispanic/ Latino o Bisexual/Pansexual o American Indian/Alaskan Native o Asexual o Arab/Middle Eastern or Arab American o Heterosexual o Asian/Asian-American o Queer o Pacific Islander o Questioning o Other (Specify) ______o Other______o Non applicable-I would prefer not to identify o Non applicable-I would prefer not to identify

Are you an international student? No / Yes If yes, what is your country of origin? ______

Please list parents, siblings, and other significant family members below: Family relationship: Age: Occupation: Education: ______CMHS Confidential Student Information Form

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If there are any other significant people in your life (e.g., friends, partners, mentors, etc.), please list them here: ______

Are you currently or have you ever been to counseling or had mental health treatment before? No Yes (If Yes, Please Describe) ______More questions on opposite side  Have you or any family member had a history of medical, mental health, or substance abuse issues? No Yes (If Yes, Please Describe) CMHS Confidential Student Information Form

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List any medications including dosages, purpose, prescriber and how long you have been taking them: ______

Are you currently experiencing any of the following? (Please check all that apply)

⃞ Stress ⃞ Irritable ⃞ Racing thoughts ⃞ Anxious ⃞ Hopeful ⃞ Success ⃞ Worthless ⃞ Appetite Changes ⃞ Nightmares ⃞ Happy ⃞ Adjustment/Transition ⃞ Mood swings ⃞ Feeling helpless ⃞ Worthwhile ⃞ Being good to yourself ⃞ Relationship issues ⃞ Guilty ⃞ Unmotivated ⃞ Abuse Issues ⃞ Feeling connected ⃞ Family concerns ⃞ Low self-esteem ⃞ Acting Impulsive ⃞ Lonely ⃞ Feeling loved ⃞ Homesick ⃞ Isolated ⃞ Sleep Changes ⃞ Self harm (cutting, ⃞ Physically active (more/less) scratching, burning) ⃞ Skipping class ⃞ Numbness ⃞ Shopping sprees ⃞ Purging ⃞ Relaxed ⃞ Grief/Loss ⃞ Poor ⃞ Too much time ⃞ Eating concerns ⃞ Questions about sexuality concentration online ⃞ Identity issues ⃞ Crying easily ⃞ Binge drinking ⃞ Trauma ⃞ Cultural adjustment ⃞ Confused ⃞ Procrastination ⃞ Using drugs ⃞ Angry ⃞ Concerns about CMHS Confidential Student Information Form

sexual behavior/health ⃞ Worried about future ⃞ Academic ⃞ Chronic health ⃞ Unpleasant thoughts ⃞ Paranoid difficulties issues that won’t go away ⃞ Conflicts with friends ⃞ Being reckless ⃞ Excessive use of ⃞ Harassment medicine ⃞ Being ⃞ Body image ⃞ Other______threatened concerns

Please briefly describe what is happening in your life that prompted this appointment: ______

Please briefly list any recent major changes in your life: ______

What are you hoping to accomplish in therapy at this time? ______

Is there anything else that we did not ask that you feel we should know about you? CMHS Confidential Student Information Form

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INFORMATION PROVIDED TO COUNSELORS IS CONFIDENTIAL WITHIN THE LIMITS OF OUR INFORMED CONSENT AGREEMENT. PLEASE REVIEW ACCOMPANYING CONFIDENTIALITY POLICY.