Counseling Services Intake Form

*Required fields

Student ID *

Date *

Major *

First Name *

Middle Initial *

Last Name *

Age *

Date of Birth *

0/0/0000

Gender Identity *

MaleFemaleOther

If other is selected please explain

Race/Ethnicity *

If other is selected please explain

Address *

(Street, City, State, Zip)

Phone Number *

(000) 000-0000

May we leave a message? *

YesNo

Email *

johndoe@email.sc.edu

May we send a message? *

YesNo

Place of Employment

Work Number

(000) 000-0000

Emergency Contact Person *

Relationship to Student *

Emergency Contact Phone Number *

(000) 000-0000

Referral *

If other is selected please explain

Current Medications *

Significant Medical Conditions/Disabilities *

Have you been treated for mental health issues? *

YesNo

If yes, please specify

Facility/Provider

Dates of Treatment

(Month/Year)

Problem

The University of South Carolina Lancaster Counseling Services is provided free of charge to active students. Counseling records are NOT a part of your academic records and are held in strict confidence. Please review my Professional Disclosure Statement, Informed Consent, and Notice of Privacy Policy and sign those forms to bring in to your first appointment. If you have any questions, please call call the Counseling Services at 803-313-7162 or email marytlee@mailbox.sc.edu.

Student Signature

Please type your full name above as your electronic signature

My USC Lancaster

(All counseling files are held in strict confidence)