Defiance College Counseling Center     Student Data Sheet - Part 2
PLEASE COMPLETE THE FORM AND SUBMIT IT BEFORE YOUR FIRST APPOINTMENT


INDICATE IF AND WHEN YOU HAVE HAD THE FOLLOWING EXPERIENCES:
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Name *
Student ID# *
Date *
1. Attended counseling for mental health concerns *
2. Taken a prescribed medication for mental health concerns *
3. Been hospitalized for mental health concerns *
3a. When was the last time? *
4. Felt the need to reduce your alcohol or drug use *
4a. When was the last time? *
5. Others have expressed concern about your alcohol or drug use *
5a. When was the last time? *
6. Received treatment for alcohol or drug use *
6a. When was the last time? *
7. Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, etc.) *
7a. When was the last time? *
8. Seriously considered attempting suicide *
8a. When was the last time? *
9. Made a suicide attempt *
9a. When was the last time? *
10. Considered causing serious physical injury to another person *
10a. When was the last time? *
11. Intentionally caused serious physical injury to another person *
11a. When was the last time? *
12. Someone had sexual contact with you without your consent (e.g., you were afraid to stop what was happening, passed out, drugged, drunk, incapacitated, asleep, threatened, or physically forces) *
12a. When was the last time? *
13. Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure) *
13a. When was the last time? *
14. Experienced a traumatic event that caused you to feel intense fear, helplessness, or horror *
14a. When was the last time? *
15. Please select the traumatic event(s) you have experienced *
Check all that apply
Required
15a. If you selected anything for the previous question, please briefly describe the event(s):
16.  Think back over the last two weeks.  How many times have you had five or more drinks* in a row (for males) OR four or more drinks* (for females)? (*A drink is a 12 oz. bottle/can of beer, an 8 oz. glass of wine, a 12 oz. wine cooler, a shot glass of liquor or a mixed drink) *
17.  Think back over the last two weeks.  How many times have you smoked marijuana? *
18.  Think back over the last two weeks.  How many time have you used any other substance (e.g., prescription meds that weren't yours or you were using in a way other than was prescribed, K-2, bath salts, heroin, cocaine, huffing chemicals, etc.) *
19.  Please indicate how much you agree with this statement:  "I get the emotional help and support I need from my FAMILY." *
20.  Please indicate how much you agree with this statement:  "I get the emotional help and support I need from my SOCIAL NETWORK (e.g., friends & acquaintances)." *
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