Your safety and well-being matter to us KPU Counselling Services is aware that students may experience situations that are serious, emotionally distressing and/or require immediate attention. Because our intake drop-ins are first come, first served, it’s important that you let us know if any of the following apply to you today: I am having suicidal thoughts I am having thoughts about harming another person I think I may be seeing or hearing things that no one else does I recently witnessed or experienced a traumatic event I am concerned for my own safety A loved one of mine has recently died If you answered “Yes” to any of the above situations, please inform our Counselling Assistant. You do not need to provide any details to the Assistant. A counsellor will speak with you to briefly assess your situation and recommend how to proceed. Contact Information First Name Last Name Student Number Age Student Status - Select -Full-timePart-time Preferred Phone Number To contact you about appointments Ok to leave a message - Select -YesNo What is your preferred name? If different from above Current Address Family Doctor Name/Location Doctor Phone Number Emergency Contact Name Emergency Contact Phone Number Relationship to Student Address and Phone Number of Hospital nearest to you In case of emergency Telephone of Crisis Line accessible in your location Current Term Availibility Option 1 Time - Select -9 - 10 AM10 - 11 AM11 AM - 12 PM12 - 1 PM1 - 2 PM2 - 3 PM3 - 4 PMAFTER 5 PM Campus - Select -KPU Civic PlazaKPU LangleyKPU RichmondKPU SurreyKPU Tech Day of the Week - Select -MondayTuesdayWednesdayThursdayFriday Availibility Option 2 Time - None -9 - 10 AM10 - 11 AM11 AM - 12 PM12 - 1 PM1 - 2 PM2 - 3 PM3 - 4 PMAFTER 5 PM Campus - None -KPU Civic PlazaKPU LangleyKPU RichmondKPU SurreyKPU Tech Day of the Week - None -MondayTuesdayWednesdayThursdayFriday Availibility Option 3 Time - None -9 - 10 AM10 - 11 AM11 AM - 12 PM12 - 1 PM1 - 2 PM2 - 3 PM3 - 4 PMAFTER 5 PM Campus - None -KPU Civic PlazaKPU LangleyKPU RichmondKPU SurreyKPU Tech Day of the Week - None -MondayTuesdayWednesdayThursdayFriday On the schedule below please select the times you are ABLE to attend counselling this term and your preferred campus location. Counselling Intake First Name Last Name Student Number What is your preferred name? If different from above How do you identify - Select -MaleFemaleTransgenderNon-binaryOther What pronoun do you go by? Are you an international student? - Select -YesNo First Language Ethnic Origin Country of Birth How long in Canada Currently Registered in courses at KPU? - Select -YesNo Student Status - Select -Full-timePart-time What program are you studying at KPU? Do you have access to extended health insurance, or other means of paying for private counselling off-campus? - Select -YesNoNot sure Other Resources - None -Social NetworkFamilySpiritualOther Reasons for seeking counselling What is your main concern? How much does this interfere with your: How much does this interfere with your: Academic Performance? - Select -Not at allSomewhatModeratelyExtremely Emotional Well-being? - Select -Not at allSomewhatModeratelyExtremely Social Relationships/Social Activities? - Select -Not at allSomewhatModeratelyExtremely Daily Routine? - Select -Not at allSomewhatModeratelyExtremely How long have you been experiecning this/these problem(s)? Have you had any past counselling experience? - Select -YesNo Are you currently seeing another counselling or other health care professional? - Select -YesNo Please specify Are you currently dealing with legal issues or an ICBC claim? - Select -YesNo Do you take any of the following? Alcohol - Select -YesNo Number of drinks per occasion Occasions per month Marijuana - Select -YesNo Frequency - Select -DailyWeeklyMonthly Do you take drugs to stay awake? - Select -YesNo E.g. Ritalin, Dexedrine, Caffeine Other Drugs - Select -YesNo E.g. Cocaine, Ecstasy, Meth, Mushrooms, Heroin Prescribed medication/For what purpose Please check any items that you are currently concerend about and at what level Academic Concerns - None -Not at allSomewhatModeratelyExtremely Adjusting to University - None -Not at allSomewhatModeratelyExtremely ADHD/Learning disabilities - None -Not at allSomewhatModeratelyExtremely Anger - None -Not at allSomewhatModeratelyExtremely Anxiety - None -Not at allSomewhatModeratelyExtremely Appetite - None -Not at allSomewhatModeratelyExtremely Compulsive behaviours - None -Not at allSomewhatModeratelyExtremely Concentration/Attention difficulties - None -Not at allSomewhatModeratelyExtremely Current living situation/Housing - None -Not at allSomewhatModeratelyExtremely Cutting or self-injury - None -Not at allSomewhatModeratelyExtremely Depression - None -Not at allSomewhatModeratelyExtremely Difficulty sleeping - None -Not at allSomewhatModeratelyExtremely Disordered eating/Body image - None -Not at allSomewhatModeratelyExtremely Family concerns - None -Not at allSomewhatModeratelyExtremely Finances - None -Not at allSomewhatModeratelyExtremely Grief/Bereavement - None -Not at allSomewhatModeratelyExtremely Gender identity - None -Not at allSomewhatModeratelyExtremely Internet/Video game use - None -Not at allSomewhatModeratelyExtremely Loneliness/Homesickness - None -Not at allSomewhatModeratelyExtremely Mood instability - None -Not at allSomewhatModeratelyExtremely Procrastination/Motivation - None -Not at allSomewhatModeratelyExtremely Physical abuse or assault - None -Not at allSomewhatModeratelyExtremely Physical abuse history - Select -PastPresent Sexual abuse or assault - None -Not at allSomewhatModeratelyExtremely Sexual abuse history - Select -PastPresent Sexuality/Sexual identity/Orientation - None -Not at allSomewhatModeratelyExtremely Substance abuse (Alcohol/Drugs) - None -Not at allSomewhatModeratelyExtremely Sudden death or suicide of someone you know - None -Not at allSomewhatModeratelyExtremely Trauma - None -Not at allSomewhatModeratelyExtremely Safety Concerns Are you currently having thoughts of suicide? - Select -YesNo Have you ever had thoughts of suicide? - None -Past weekMonthYear Do you have a suicide plan? - Select -YesNo Have you made a suicide attempt in the past? - Select -YesNo Do you see or hear things other people do not? - Select -YesNo Do you have intent or plan to hurt or cause physical harm to someone else? - Select -YesNo Disclaimer KPU Counselling Services takes the protection of your privacy very seriously. In accordance with our professional association’s ethical guidelines, all information discussed and/or recorded during counselling sessions is considered private and is held in strict confidence. Your counsellor may consult with counsellor colleagues to ensure that you are receiving the best care possible. All clinical notes are accessible to counsellors at KPU. We will not release information to anyone, whether an individual or an agency, without your consent. Exceptions to confidentiality include: Duty to warn if you or someone you know is in imminent danger or at risk When there is reasonable cause to believe a child is in need of protection When there is a court order to release records Please note that we cannot ensure the confidentiality of communication via email and cell phones. If you need to miss an appointment for any reason, we require minimum notice of 48 business hours to cancel. Failure to provide adequate notice or “no shows” may result in termination of services. I have read, understand and agree to the information provided above