Student Counseling Form
Student Counseling Form
Nationality Religion
Graduate
Other
Current Year
Address Telephone
(if different from Number
College)
E.mail
Friend Supervisor
Partner
Date: Signature
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(To be filled in by the Counselling Service)
The information you provide will help us to understand your needs and arrange for
you to see an appropriate counselor, so it is useful to have some information about the
problem. The questions are intended to be through-provoking, but you do not need to give
long answers or address every sub-question if it is irrelevant, it is OK to put you would
prefer to talk about this in person if it is difficult to write about. This information will be
treated confidentially.
Please describe what has led you to your seek conselling now. How long has this been a
problem for you and what other help you had with it? How do your current difficulties
affect you?
What would you like to gain from counseling now? How would things be different if the
difficulties were resolved?
3. On a scale of 1- 10 (with 10 being the most serious), how seriously is this affecting:
How have you been coping with this problem until now?
What support do you have in your life (E.g. Family, friends, college, social activities)?
Do you have any difficulties with alcohol, drugs or food?
At you worst, do you ever feel like harming yourself or others?
5. Background
If it seems relevant, please give any ideas you may have had about the origin of the
problem.
Thank you