Student Counselling Service

@ Disted

distedcounselling@creativeartstherapy.org.my

http://www.creativeartstherapy.org.my/distedcounselling.htm

CCAT Office - Room 12 Crosby Hall. Disted College

 

 

Counselling Intake Form (Online Version) - PART A

 

The information in this form is requested for record-keeping and statistical purposes; it will not be used outside the Service in any way that identifies individuals. You can complete the form digitally. DO NOT FORGET TO CLICK ON THE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE WHEN YOU HAVE COMPLETED THE FORM.

 

Surname

First Name

Gender

Female        Male

Date of birth

     

Nationality

  

Ethnicity

   

 

School:

Status:

Full-time       Part-time   

Programme:

Level

(BA, Dip, Cert etc)

 

 

Term Time Address:

Email address:

Telephone number:

Is it OK to leave a message on your phone?

     Yes            No 

Can we contact you by email?

     Yes            No 

Which is the best way of contacting you?

    Phone             Email             SMS 

 

Referral:  Who suggested that you came to see a counsellor?  (Please tick)

 

No-one (self-referral)

Tutor

Friend

Other academic staff

Family member

Other (State)

Partner

 

 

 

Have you used a Counselling Service before?

    Yes            No 

Current medication, if any:

    

 

Other forms of help you have used previously or currently for related issue(s):

Previously

Currently

Medical Doctor

Counsellor

Psychologist

Psychotherapist

Psychiatrist

Other kind of specialist help

 

Availability

 

Please fill in the boxes below to show your availability: ‘Y’= available; ‘?’= may be available; ‘N’ = not available.  We will try and offer times when you are available but may offer non-preferred times to reduce the waiting period.  Very restricted availability is likely to delay counselling.

 

Term time:

 

 

9am

10am

11am

12md

1pm

2pm

3pm

4pm

5pm

6pm

Mon

Tue

  

Wed

Thu

Fri

 

 

Are you in Penang outside term time?  If so, please indicate the likely dates:

 

Please sign to indicate that you have read the ‘Information for anyone thinking about counselling' (available at: www.counselling.cam.ac.uk/students.html)

 

Signed (Tick 'I accept' in understanding  and agreeing to the terms of counselling,

 

 I accept   

Date

 

Please continue to Part B

 

 

 

To be filled in by the CCAT Student Counselling Service @ Disted

 

Date form returned:

 

Date acknowledged:

 

Appointment arrangements made:

 

Client allocated ID:

 


 

PART B

 

The information you provide here will help us to understand your needs and arrange for you to see an appropriate counsellor, so it is useful to have some information about the problem, even if brief. This information will be treated confidentially.

 

1. Your reasons for approaching the Counselling Service

 

Please describe what has led you to your seek counselling now. How long has this been a problem for you — and what other help have you had with it? How do your current difficulties affect you?

 

 

2. What are you hoping for from counselling?

 

What would you like to gain from counselling now? How would things be different if the difficulties were resolved?

 

     

                                      

3. Much of our work involves workshops and groups of various kinds.

Please indicate whether these might interest you?

 

·         Structured groups with a focus on practical strategies:   

·         Ongoing counselling groups:                                                         

 

4. Is there anything else that you think is important which we should know?

 

 

Thank you.

Click here to return to http://www.creativeartstherapy.org.my/distedcounselling.htm