Palm Beach State College Student Counseling Center Case Management Intake Form
Student Name:
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First Name
Last Name
Student ID Numer:
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Date:
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Month
-
Day
Year
Date
Date of Birth:
*
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Month
-
Day
Year
Date
Age
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Phone Number
*
Please enter a valid phone number.
Is it safe to contact you at this phone number?
*
Please Select
Yes
No
Palm Beach State Email Address:
*
example@my.palmbeachstate.edu
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
First Name
Last Name
Relationship:
*
Phone Number:
*
Please enter a valid phone number.
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Other
Children
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Yes
No
If yes, please list their ages and any relevant information
Living Situation
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Alone
With Family
With Friends
Other
Current Employment Status
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Employed Full-Time
Employed Part-Time
Unemployed
Student
Retired
Other
Occupation
*
Employer
*
Source of Income
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Employment
Social Security
Disability
Unemployment
Other
Monthly Income
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Monthly Expenses
*
Please describe the main issues or problems you are experiencing:
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How long have you been experiencing these issues?:
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Have you sought help for these issues before?
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Yes
No
If yes, please provide details:
Have you ever received counseling or case management services from Palm Beach State College Student Counseling Center in the past?
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Yes
No
If yes, please describe whom you worked with, what services were provided, and what semester?
What are your goals for seeking case management services?
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Are you interested in a support group? If so, which?
Around the Table - Making the Pantry Work for you
Basic Needs - Community Resources
Beyond Borders
Creative Expressions
FUNctional mental health
Mastering Your Emotions
NAMI
Return/Relearn - Returning to School
Shifting Sands - Sand Tray Therapy
Stress Free Living
Turning Pages Together
Tranquil Minds - Meditation Group
Talk it Out Tuesday
Other
Please state the best times and days that you would prefer your appointment:
*
The times and dates you select are not guaranteed.
What campus do you prefer?
*
Please Select
Lake Worth
Boca Raton
Palm Beach Gardens
Loxahatchee
Belle Glade
Is there anything else you would like us to know?
*Your signature below indicates that the information you have provided above is truthful.
Date
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Month
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Day
Year
Date
Print Student Name
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Student Signature
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Submit
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