1. DATE: _______________ Fresno City College Madera Center Reedley College Clovis Community College S.C.C.C.D. REQUEST FOR PSYCHOLOGICAL SERVICES FORM CONFIDENTIALITY: Everything shared here is treated as CONFIDENTIAL Information. Psychological Services staff are mandated reporters, so information related to harm to self or others, child abuse, elder abuse, or dependent adult abuse will result in staff contacting the proper authorities. By initialing here, you are stating that you understand the limits of confidentiality. _______________ Phone (primary) __________________ Ok to call? Yes No Ok to leave message? Yes No Phone (secondary) __________________ Ok to call? Yes No Ok to leave message? Yes No E-Mail (if applicable) ____________________________________ Ok to E-mail? Yes No _____________________________________________________________________________________ Date of Birth: _____________________ Birthplace: __________________________________ Male: _______ Female: _______ Age: _______ Primary Language _______________________ Ethnicity : African-American Asian Biracial Caucasian Hispanic Native-American Other Marital Status : Never Married Live with Significant Other Married Separated Divorced Widowed Live with Parent ? YesNo ______________________________________________________________________________________________________ Revised 2/27/15 Monday Tuesday Wednesday Thursday Friday *List ALL Your Available times between 8AM-4PM Please Complete The Psychological Services Department at Fresno City College strives to accommodate the schedules of every student. Students with limited availability, however, may experience a longer than expected waiting period. Appointments are 50 minutes long and are scheduled at the top of the hour. If for any reason the session is interrupted, it will not count against the allotted number of sessions you are eligible for. We respectfully ask you to keep this in mind when providing your availability. Compassion. Action. Change. Initials STUDENT ID : ________________ First visit to Psychological Services? YesNo If no, please indicate date of last visit: Year _____ Fall/Spring Are you currently taking medications? YesNo If yes, please bring a list of medications to your first appointment Are you thinking of harming yourself YesNo Are you thinking of harming someone else? YesNo ___________________________________________________________________________________ Last NameFirst NameMIMaiden Name __________________________________________________________________________________ Street ( Best address to send correspondence, if needed ) City, StateZip Code

2. Fresno City College Student Concerns Checklist ______________________________________________________________________________________________________________________________________ Please check only the issues you are currently experiencing (within the last two weeks) Please circle which services interest you (circle all that apply): Individual Therapy Group Therapy Both Emotional Concerns ____ Sad, depressed, hopelessness ____ Tired, lack of energy ____ Decrease in drive or motivation ____ Isolation or feelings of loneliness ____ Irritability, hostility, anger ____ Feelings of worthlessness ____ Relationship concerns Stress or Anxiety Concerns ____ Fear or anxiousness ____ Panic attacks ____ Stress, worry ____ Unwanted or persistent intrusive thoughts ____ Restlessness or feeling keyed up or on edge ____ Shyness/discomfort in social situations Thinking Concerns ____ Problems remembering ____ Difficulty making decisions ____ Hearing voices, or seeing things that others don’t ____ Told my behavior is odd or eccentric ____ Poor concentration or focus Other Concerns ____ Spiritual concerns ____ Gender identity issues ____ Sexual identity/orientation questions ____ Concerns about family ____ Adjustment to college ____ Cultural conflict or prejudice ____ Financial problems ____ Legal problems ____ Grief/loss ____ Eating disorder Other: ____________________________ Of the concerns you checked please choose the 3 that are of the greatest concern to you. Rate the level of distress each is causing you: #1 Concern _____________________________________________________________ ____ Minimal ____ Mild ____ Moderate ____ Severe #2 Concern _________________________________________________________________ Minimal ____ Mild ____ Moderate ____ Severe #3 Concern _________________________________________________________________ Minimal ____ Mild ____ Moderate ____ Severe ________________________________________________________________________________________________________________________________________________________________________________ By signing below you acknowledge that you have read and understand your clinician’s role as a mandated reporter and the limits of confidentiality. _______________________________________________________________________________________________________ Emergency Contact Person _____________________ Relationship _____________________________ Phone Number __________________ Please initial for permission to call emergency contact ____________ Who referred you to Psychological Services? 1 Instructor 2 Friend 3 Self 4 Family 5 Counselor 6 Coordinator 7 Dean 8 Vice President 9 Nurse 10 District Police 11 FCC Website 12 Other ________________________________ Name of Person who referred you: __________________________________________________ Initials Client SignatureDate Compassion. Action. Change.