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Personal Counseling

Personal Counseling Request Form

Saint Xavier’s Counseling Services abides by the Ethical Standards of the American Counseling Association.  Your request for services and the information you share are considered confidential in accordance with these standards.  No information will be released without your written consent.  Please review the limits of confidentiality on the Consent for Services information sheet.

Fields marked with an (*) are required.

Mandated Services:

Contact Information

Name*:
   
First Middle Last
Current Address*:
Street Address
   
City State ZIP Code
Permanent Address*:
Same as above
Street Address
   
City State ZIP Code
E-mail Address*:
Reenter E-mail Address*:
Primary Phone*: - -
Secondary Phone: - -
Ok to Contact:
  Primary Phone
  Secondary Phone
  E-mail
Best Day(s) and Time(s) to Contact*:
500 characters remaining
Day(s) and Time(s) Available for an Appointment*:
500 characters remaining
Emergency Contact Name*:
Emergency Contact Phone*: - -
Current Reason for
Seeking Services*:

1500 characters remaining

Demographic Information

Gender:
  Prefer No Response
  Male
  Female
  Transgender
Date of Birth*:
Ethnicity:
  Prefer No Response
  African American
  Asian American
  Caucasian American
  Latina/Latino
  Mexican American
  Middle eastern
  Multi-Racial
  Native American
  Other:
How did you find out
about our services?
  Staff/Faculty
  Student
  Family/Friend
  Bulletin Board
  Flyer
  FOCUS/TSO
  Web Site
  Student Handbook
  Other:

Academic Information

Class Standing*:
  Freshman
  Sophomore
  Junior
  Senior
  Graduate
  Alumnus
Student ID Number*:
Major:
Minor:
GPA:
Current Student*:
  Yes
  No
Student Status:
  Full Time Student
  Part Time Student
Transfer Student:
  Yes
  No
Student Success Program (SSP) Participant:
  Yes
  No
Student Athlete:
  Yes
  No
Sport(s):
Employed:
  Yes
  No
Hours Worked Per Week:
Job Title:

Health Information

Health Insurance:
  Yes
  No
Health Insurance Company:
Previous Counseling or
Psychiatric Treatment:
  Yes
  No
Previous Counseling
Date and Issue:

1500 characters remaining

At busy times during the semester, it is sometimes necessary for Counseling Services to begin a waitlist in order to adequately serve those students already engaged in services through our office. Students will be assessed through the intake process, but then may be placed on the waitlist or referred to off-campus services. If you choose, for any reason, to not engage in services through SXU Counseling Services, please refer to the Mental Health Resources brochure for other service provider options and emergency resources.

Acknowledgements*

I give consent for Counseling Services to contact me regarding initiating services, and acknowledge that the information on this form is accurate to the best of my knowledge.