Counseling and Wellness Center Intake Form
Name and ID
First Name
Last Name
Student ID (Empower) Number
Program of Study
Address
Street Address
Address Line 2
City
State
Postal / Zip Code
Contact Information
Mercy College Email Address
Phone Number
How may we contact you?
It is OK to call
It is OK to leave a message
It is OK to send an email to your Mercy College email address
About You
Age
Gender
Male
Female
Non-binary
Transgender
Other
If other, please specify
Ethnicity
African/American
American Indian
Asian/Pacific Islander
Latino
White/Caucasian
Other
If other, please specify
Military Service Member
Yes
No
Military Branch
Emergency Contact
Emergency Contact Name
Relationship
Phone Number
Counseling Services
Who referred you for counseling services?
Self-referred
Faculty
Academic Advisor
Friend/Classmate
Campus Minister
Accessibility Services
Tutor
Other Staff Member
Family Member
Healthcare Provider
Other
If other, please specify
Have you participated in counseling services in the past?
Yes
No
Where?
When?
Have you ever been hospitalized as a result of your participation in counseling or therapy?
Yes
No
Please list any medical conditions and current medications
What brings you to counseling today?
Please check each concern that you are currently experiencing, or have experienced in the past month
Depression
Anxiety
Eating Disorder
Suicidal Thoughts/Plans/Attempt
Substance Abuse Issues
Family/Friend relationship issues
Procrastination
Parental Alcohol/Drug Use
Sleeping Problems
COVID-19 Related Stress
Test Anxiety
Speech/Performance Anxiety
Stress Management
Disability Related Issues
LGBTQ+ Related Issues
Self Esteem/Confidence
Inadequate Academic Preparation
Grief/Loss
Romantic Relationship Issues
Body Image
Physical or Sexual Abuse
Intimate Partner Violence
Attention/Focus Difficulties
Other
If other, please specify
Is there any additional information you wish to share?
Mercy College of Ohio, a Catholic institution with a focus on healthcare, educates and inspires students to lead and serve in the global community.