CONFIDENTIAL TUJ Counseling Office Intake Form Section I

-1(office use only）Phone intake
In person
Walk-in
＃
Initials
CONFIDENTIAL
TUJ Counseling Office
Intake Form
The following information will help us to serve you better and save time in your first session.
Please fill out this form and slip underneath the door if a counselor is not available.
下記の情報は、より良いサービスの提供と初回の面談にて時間を有効に使うのに役立ちますのでご協力下さい。
カウンセラー不在の場合、記入後ドアの下に入れて下さい。
Date(日付):
Section I: IDENTIFYING INFORMATION 個人情報
Name（氏名）
last（姓）
first（名）
Ethnicity (エスニシティ):African-American
Arab
Current Address（現住所）:
Home phone:
Cell phone:
E-mail address:
Emergency Contact（緊急連絡先）:Name
Program： AEP
Asian-American
Caucasian
OK to call and identify
OK to call and identify
Chinese
Yes
Yes
No
No
Undergraduate (Bridge / Japan Admit / Study Abroad)
Multiethnic Other
Law
MBA
Yes
Yes
Yes
日本語
Who referred you to the Counseling Office?
Self
Orientation
Flyer
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No
English
Faculty
OSS
Family
AAC
Friend
Other Staff:
Referral Name:
Other
相談内容：当てはまるものを全てチェックしてください。
□Abuse/Assault(虐待・暴力) □Academic
concern(学業)
□Anxiety/worry(不安・心配) □Attention
problem(注意力不足)
□Family
)
どなたからカウンセリングオフィスを紹介されましたか？
Brochure
Concerns: Please check all that apply.
Problems(摂食問題)
No
No
No
TESOL Other
Did you transfer to TUJ? 編入生？□ Yes (specify:
Language Preference(希望する言語):
issues(家族問題)
□Adjusting
□Pregnancy/abortion(妊娠・中絶) □Relationship
Skills (勉強の仕方)
to college(学校への適応)
□Career
Concern(就職)
□Finances(お金) □Goal
□Homesick(ホームシック) □Identity(アイデンティティ) □Learning
□Stress(ストレス) □Study
Korean
Other
Year in School (学年)：
Major(主専攻):
Referral Type
Japanese
Male
OK to leave message
OK to leave message
OK to receive E-mail
) Contact
(Relationship:
Starting Date (入学時期):
□Eating
middle
Gender（性別）
：Female
Age（年齢）
Date of Birth (生年月日)
(人間関係)
□Suicidal
□Alcohol/drugs(飲酒・薬物) □Anger (怒り)
□Decision
Making(意思決定)
setting/attaining(目標設定・達成)
disability (学習障害)
□Depression(憂鬱な気分)
□Health
concerns(健康)
□Manic(躁病) □Panic(パニック)
□Religion(宗教) □Self-esteem(自尊心) □Sexuality(性) □Sleeping
thoughts(自殺企図)
problem(睡眠)
□Other（その他）
Please describe in details:
How long has this been a problem? (e.g., days, weeks, months, etc.)
この問題に悩み始めてどの位たちますか？(例：日、週、月単位で)
In the last 2 weeks, have you been afraid you might hurt yourself or someone else?
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Yes (はい)
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No (いいえ)
過去 2 週間のうち、自分もしくは誰かに危害を加えるのではないかと怖くなったことはありますか？
Please check the services you are interested in: (check all that apply) 受けてみたいと思うサービスを選んでください。（当てはまるもの全て）
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Academic assistance 修学支援
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One- or Two-session problem solving 1-2 回の面談での問題解決
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Individual short-term counseling (12 or fewer sessions) 短期個人カウンセリング（12 回以下）
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Individual counseling (long-term) 長期個人カウンセリング
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Group counseling グループカウンセリング
Please circle specific times you are available for appointments: 予約可能な時間にまるをしてください。
Monday
Tuesday
Wednesday
Thursday
Friday
10am
10am
10am
10am
10am
11am
11am
11am
11am
11am
12pm
12pm
12pm
12pm
12pm
1pm
1pm
1pm
1pm
1pm
2pm
2pm
2pm
2pm
2pm
3pm
3pm
3pm
3pm
3pm
4pm
4pm
4pm
4pm
4pm
Rev. 1/09
-2(office use only）Phone intake
In person
Walk-in
＃
Initials
CONFIDENTIAL
Section I: IDENTIFYING INFORMATION (Cont’d) 個人情報（続き）
Residence 住まい
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Living situation
Apartment アパート・マンション
House 家
TUJ Dorm TUJ の寮
TUJ housing TUJ 関係のハウジング
Other その他
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生活状況
Credits this term 今学期の履修単位
Alone 一人暮らし
Roommate(s) ルームメイト
Parents/siblings 親・兄弟姉妹
Partner/Spouse パートナー・配偶者
MARITAL STATUS 婚姻および親しい関係
□ Single 独身
□ Dating 交際中
□ Married/Partnered 既婚・パートナーがいる
□ Separated 別居中
□ Divorced 離婚
□ Other その他
1-5
6-10
11-15
16-20
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Over 20
Leave of Absence 休学中
仕事の有無
Are you employed?
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Yes Where どこで
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No
Hours/wk 週の就業時間
Section II: HEALTH AND FAMILY INFORMATION 健康と家族について
Are you currently (or within the past year) under the care of a medical doctor?
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Yes はい
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No いいえ
現在（もしくは過去 1 年以内に）お医者さんにかかっていますか？
If yes, for what condition：
はいの場合、どのような症状：
Do you have any other significant medical conditions?
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他に深刻な病状がありますか？
Yes はい
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No いいえ
If yes, for what condition：
はいの場合、どのような病状：
Are you currently taking any medications, herbs or Chinese herbs?
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Yes はい
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No いいえ
現在、薬やハーブおよび漢方薬を飲んでいますか？
Name of medication/herb(s): 薬、ハーブおよび漢方薬の名前
Who prescribed it for you: 誰が処方しましたか
Do you have a disability?
If yes, please describe:
障害がありますか？
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Yes はい
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No いいえ
はいの場合、説明して下さい
Have you had previous counseling or psychotherapy? カウンセリングやサイコセラピーの経験がありますか？
Where どこで
Name of counselor カウンセラーの名前
When & How long いつ＆どの位
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Yes はい
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No いいえ
Does any member of your family suffer from alcoholism, depression, anxiety, or anything that can be considered an emotional or mental
difficulty? 家族の中でアルコール依存症、うつ、不安症やその他の心理的な問題を抱えている人がいますか？ □ Yes はい □ No いいえ
If yes, please describe:
はいの場合、説明して下さい
Do you use alcohol or drug to (check all that apply): □ Social?付き合いで □ Manage Stress?ストレス発散 □ To relax?リラックスしたい
アルコールやドラッグを使うことがある（当てはまるもの全て）：□ To change mood?気分転換したい □ For sleep?よく眠りたい
How often do you use alcohol or drug? アルコールやドラッグの使用頻度：
□ More than once a week 週 1 回以上 Æ Do you feel that you need the substances to get by?
□ Once a week or less 週 1 回かそれ以下
□ Do not use 使わない
生きる為にこうした薬物が必要？□Yes はい□No いいえ
Have you been in any abusive relationships? これまでに虐待的な関係にいたことがありますか？
If yes, please check following:はいの場合、下記をチェックしてください。
Type of Abuse(虐待の種類)
Type of Abuser(加害者の種類)
□ Physical abuse 身体的虐待
□ Parent(s) 親
□ Verbal abuse 言葉の虐待
□ Brother/Sister 兄弟姉妹
□ Emotional abuse 感情的虐待
□ Partner 恋人・パートナー
□ Sexual abuse 性的虐待
□ Friend(s) 友人
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Yes はい
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No いいえ
Professor 教授
Neighbor 隣人
Other その他
□ Neglect ネグレクト
When & How long? いつ & どの位？
Family Information ご家族について
Relationship 関係
Mother 母親
Age 年齢
Supportive？頼りにできる？
Y
N
Relationship 関係
Spouse 配偶者
Age 年齢
Supportive？頼りにできる？
Y
N
Father 父親
Y
N
Children 子供
Y
N
Brother(s) 兄弟
Y
N
Grandmother 祖母
Y
N
Sister(s) 姉妹
Y
N
Grandfather 祖父
Y
N
If parents are separated/divorced, how old were you then? 両親が別居・離婚の場合、あなたは何歳でしたか？
-3(office use only）Phone intake
In person
Walk-in
Initials
＃
CONFIDENTIAL
Section III: DESCRIPTION OF PRESENTING PROBLEMS 今抱えている悩みについて
Please use the following scale to answer the next three questions:
次の３つの質問に対して隣の基準からランク付けしてください。
1
2
Not at all 全然 Mildly 少し
1. How serious you estimate is your concern(s) at this time?
3
Moderately 中位
4
Highly 非常に
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現在あなたの悩みはどのくらい深刻だと思いますか？
2. How motivated are you to resolve your concern(s)?
この悩みを解決するのにどのくらいやる気がありますか？
3. How optimistic are you that your concern(s) can be resolved?
あなたの悩みが解決されるのをどの程度楽観的に捉えていますか？
For your current concern, please take a look at the following page in which you will find a list of problems that people commonly face.
The list surveys family, academic, social, spiritual, and other problems of everyday life.
Read the list carefully and check all the item(s) that are causing you the most trouble at this time.
あなたが現在抱えている問題について、次ページの「気がかりなことのリスト」を参照して下さい。この一覧は、一般によく聞かれる悩みを家族、
学業、社交、友達といった日常生活の場面別にまとめたものです。これらの項目によく目を通して頂き、現在あなたが困っている、心配している
もの全てにチェックをつけて下さい。
Please estimate how much your concerns are affecting the following areas of your life:
今の悩みがあなたの生活の下記の場面にどの位影響していると思いますか？
Academic 学業面
Social 社交
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No interference 全く影響なし
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No interference 全く影響なし
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Mild interference 少し影響あり
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Mild interference 少し影響あり
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Moderate interference ある程度影響あり
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Moderate interference ある程度影響あり
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Severe interference かなり影響あり
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Severe interference かなり影響あり
Anything else you would like us to know about you: その他私たちに知っておいてほしいと思うことを書いてください。
-4(office use only）Phone intake
In person
Walk-in
Initials
＃
CONFIDENTIAL
Concern Checklist:
Anxiety
Sadness
Fears
Substance Use
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Bad dreams/Nightmares
Being overly excited
Difficulty relaxing
Feeling nervous
Racing thoughts
Afraid of hurting self
Difficulty concentrating
Feeling overly emotional
Feeling depressed
Suicidal thoughts/behaviors
Fear of death
Fear of failure
Fear of future
Fear of people
Irrational fears
Difficulty quitting addiction
Drinking too much alcohol
Fear if overdosing
Smoking too many cigarettes
Using drugs
Parents
Finances
Feelings
Spirituality
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Difficulty talking with parents
Parents constantly arguing
Parents being too strict
Parents interfering with life
Parents Separated/Divorced
Poor relationship with parents
Can’t make ends meet
Can’t decide on career
Spending money foolishly
Unable to find job
Worried about finding job
Worries about money
Feeling anxious
Feeing guilty
Feeling inferior
Feeling lonely
Feeling no one likes me
Feeling sad
Afraid God will punish me
Confusion about God
Feeling unaccepted by God
Failure with God
Feeling abandoned by God
Inability to get to church
Anger
Friends
Health
Self-Esteem
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Difficulty loosing temper
Fear that I might hurt someone
Feeling jealous
Getting into arguments
Hurting other’s feelings
Inability to express anger
Upset about past hurts
Death of close friend
Difficulty getting close w/ others
Friend emotionally upset
Friend committing suicide
Friend with serious illness
Missing good friend(s)
Picking the wrong friends
Anorexia
Bulimia
Headaches
Lack of Energy
Lack of Sleep
Racing heart
Stomachache/ulcer
Being overweight
Being underweight
Being noticed for physical appearance
Eating too much
Feeling unattractive
Hating Self
Poor eating habits
Social Situations
Sexuality
School
Guilt
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Awkward meeting new people
Being criticized by others
Being left out of things
Critical of others
Difficulty making friends
Having a bad attitude
Having few hobbies
Having strong opinions
Having little/no opinions
Lacking self-confidence
Lack of interest in activities
Uncomfortable in situations
Wish people liked me better
Concern about sexual orientation
Dating issues
Difficulties with sexual thoughts
Difficulties getting dates
Difficulties with sexual behavior
End of relationship
Involved in bad relationship
Memories of past sexual abuse
No sexual thoughts/behaviors
Questions about sex
Uncomfortable with other sex
Sexually underdeveloped
Wondering about marriage
Difficulty with professor
Difficulties with reading
Difficulties finding right major
Feeling out of place in school
Getting low/failing grades
Language problem in school
Missing school due to illness
Not enough money for school
Overloaded with work
Poor memory for work
Poor study habits
Unable to concentrate on work
Worries about grades
Family
Other
Other continued
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Death of family member
Difficulty with brother/sister
Family member with illness
Family member loosing job
Feeling homesick
Poor relationship with family
Acting strangely
Compulsive behaviors
Difficulties with reality
Family history of mental illness
Feeling strange
Gender confusion
Hearing voices
Involved in abusive situation
Little or no emotion
Loosing portions of time
Obsessive thoughts
Self-harming behaviors
Being careless
Cheating on schoolwork
Feeling ashamed of something
Getting into trouble
Giving into temptation
Involved in sexual relationship
Lacking self-control
Not being honest with others
Not taking things seriously
Stealing from others
Unable to stop bad habit
Use of pornography
Unexpected Pregnancy
OTHER (Please specify):