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Intake Questionnaire (Part 1) for Non-MA Residents
Part 1: Life, Status, Health, & Mental Health assessment questions
The Counseling Center at CELA - Non-Massachusetts Residents Form
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* Indicates required question
Email
*
Your email
Initials (two letters only, one for first name / one for last name)
*
Your answer
What brings you here?
*
Your answer
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Extremely difficult
Frequently difficult
Sometimes difficult
Not at all
What is your gender
*
Your answer
Are you currently employed?
*
Yes
No
How old are you?
Your answer
What is your orientation?
Your answer
Do you have any hobbies?
*
Your answer
Have you ever been in expressive/creative arts therapy before?
*
Yes
No
Have you ever been in counseling or therapy?
*
Yes
No
Are you currently experiencing overwhelming sadness, grief, or depression?
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Yes
No
Are you currently suicidal?
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Yes
No
When was the last time you had a plan for suicide?
*
Within the past week
Within the past month
Within the past three months
Within the past six months
Within the past year
More than a year ago
Never
Are you currently experiencing anxiety, panic attacks, or have any phobias?
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Yes
No
Have you been moving or speaking so slowly that other people might have noticed? Or the exact opposite--been so fidgety or restless that you have been moving around a lot more than usual?
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Yes--I've been moving/speaking slowly every day
Yes--I've been fidgety, restless, and moving around morethan ususal every day
Yes, I've been moving/speaking slowly most of the time but not every day
Yes, I've been fidgety, restless, and moving around more than usual most of the time but not every day
Sometimes I feel I'm moving/speaking slowly
Sometimes I feel fidgety, anxious, and moving around more than usual
Not at all
Do you have any problems or worries about intimacy?
*
Yes
No
Feeling down, depressed, or hopeless?
Yes, every day
Yes, most of the time but not every day
Frequently
Sometimes
Not at all
Clear selection
Are you currently taking any medication?
*
Yes
No
Are you having any trouble falling asleep, staying asleep, or sleeping too much?
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Yes
Often
Sometimes
Not at all
Are you feeling bad about yourself--or that you're a failure or have let yourself or your family down?
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Yes
Often
Sometimes
Not at all
Any trouble concentrating on things like reading or watching TV?
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Yes
Frequently
Sometimes
Not at all
Are you currently experiencing any chronic pain?
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Yes
No
Thoughts that you would be better off dead or of hurting yourself in some way?
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Yes, every day
Often
Sometimes
Not at all
How would you rate your current sleeping habits?
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Good
Fair
Poor
Other:
How would you rate your current eating habits?
*
Good
Fair
Poor
Other:
Do you consider yourself to be religious?
*
Yes
No
What religion do you identify with?
*
Your answer
Do you consider yourself spiritual?
*
Yes
No
How would you rate your current physical health?
*
Good
Fair
Poor
Other:
How often do you drink alcohol?
*
Daily
Frequently
Weekly
Infrequently
Not at all
Who referred you to The Counseling Center at CELA?
*
Friend
Family member
Website
Internet search
Other:
What country are you in?
*
Your answer
Which state are you in (if in the USA)?
*
Your answer
Completing this form
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Write your initials (two letters, one for your first name and one for your last name as you did at the beginning of this form) and the time and the date that you finished filling out this form in the spaces provided below. Providing your initials as well as the date and time you completed this form acknowledges that you: (1) have read and understood each individual question and the sections of this form, and the information requested and/or provided; and (2) have provided information that is accurate and correct to the best of your knowledge.
MM
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DD
/
YYYY
Time
:
AM
PM
Please sign/type your initials in the space below to complete this form. Thank you! --- The Counseling Center at CELA.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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