To serve you better we need information about the persons who access our services. All information shared will be held in the strictest of confidence. Please carefully complete all applicable sections of the form below. Step 1 of 12 - The Basics 0% Let's start with the basicsEach step of this form will help us build a better understanding of you. Please fill out each field as accurately as you can. What is your name?*Enter your name in the appropriate spaces First Middle Last Maiden Permanent Address*Include street address, town, and parish Today's Date*You do not need to change this. It will update automatically. DD slash MM slash YYYY How do I contact you?Your counsellor will often need to interact with you by phone or email (sending documents, confirming appointments etc.). The information you submit below helps them to do so. Your MICO Email Address?*Only MICO email addresses are accepted here e.g. name@themico.edu.jm or name@stu.themico.edu.jm. Enter Email Confirm Email Cell Phone*Please enter 10 digits (e.g. 876 XXX XXXX)Work Phone10 digits. Enter if applicableHome Phone10 digits. Enter if different from cell number Tell Me More About YourselfHere, you'll begin to share more specific information about yourself with the counselor. Information such as your date of birth and your religious affiliations (if any) will be requested. MICO Status*Are you a member of staff or a registered student? Student Staff Your MICO ID Number?* Your Biological Gender?* Male Female Your Age*Your Date of Birth*Enter in day - month - year format. Numbers only. Day Month Year Your Nationality* Your Religion & Denomination* How often do you attend a place of worship?* Regularly Sometimes Not at all Let's Discuss Your Home & Relationship StatusWhere and with whom you live, as well as your relationship status can have a large impact on your psychological state. Going into counselling sessions, it is important that your counsellor has a basic understanding of your home and relationship status. Where do you live?* On campus Off campus I live with/by my...* Self Spouse Roommate(s) Siblings/relatives Parent Do you have children?* Yes No How many?*What is your relationship status?* Single Committed Relationship Married Separated Divorced Widowed EmploymentWhere you work, what you do, and how you feel about work plays a large role in your mental state (as an employee). Please tell me about your employment history and experiences. What is your employment status (at The MICO)?* Temporary Full time Part time Contract Never employed Where do you work?* What is your occupation?* Employment experiences* Positive Negative Neutral Let's Discuss SchoolYou're doing great so far! Now share details of your current academic endeavors with your counsellor.Student Status* Continuing Studies Undergraduate Graduate Enrollment* Full time Part time Which faculty do you belong to?* Humanities & Liberal Arts Science & Technology Education Programme of study* Entrace Date* Day Month Year Anticipated graduation date* Day Month Year Let's Discuss Counselling - Part 1You're a little over half way finished! Here, the counsellor will ask about your mental health history and your reasons for seeking counselling. Try to be as truthful and expressive as possible when responding to these questions. As always, anything your say here will be kept in the strictest of confidence as per our agreement through the Informed Consent form. Who referred you to the Counselling Service?* Self Family Friend Other Have you been experiencing any of the following over the past month?* Anxiety Loss of interest in pleasurable things Depression Sleeping Problems Irritability, anger Suicidal feelings Change in appetite Active plans to harm self Are you presently or have you been on medication for this or a related condition?* Yes No Please state when and where*Do you have any disability or mental condition you would like your therapist to know about?* Yes No Please describe the condition as clearly as possible*Have you been in therapy or hospitalized for mental health reasons before now?* Yes No Please state when and where* Let's Discuss Counselling - Part 2Please try to be as clear and truthful as possible when filling out the following questions. It's okay to take your time and think on the answers. What is your main reason for coming to the counselling service at this time?*What have you tried to do about the cause and/or effects of your situation? Describe solutions attempted:*What have you tried to do about the cause and/or effects of your situation? Describe solutions attempted:*What do you hope to achieve in your work with the counsellor?*Please list a few of your strengths/abilities*Please use the "(+)" icon to the right of the field to add a new line for each strength/ability Add RemoveIs there any additional information you wish to share?* Your Family Tree - Parents and SiblingsUnderstanding your family structure is often very important to the counselling process. Please fill out the fields below as accurately as possible. What is your mother's name?* Her Age?* Her Occupation?* What is your father's name?* His Age?* His Occupation?* List the children of both parents’ union (including you)*Please use the "(+)" icon to the right of the field to add a new line for each childAge of childSex of childOccupation Add RemoveDoes your mother have any children from another union?* Yes No List the children of your mother's other union(s)*Please use the "(+)" icon to the right of the field to add a new line for each childAge of childSex of childOccupation Add RemoveDoes your father have any children from another union?* Yes No List the children of your father's other union(s)*Please use the "(+)" icon to the right of the field to add a new line for each childAge of childSex of childOccupation Add Remove Your Family Tree - Spouse and ChildrenUnderstanding your family structure is often very important to the counselling process. If in the earlier stages of the form you said you were married, committed or separated but had no children, you will be asked for your spouse's name. If you selected that you have children but are either not married or in a committed relationship, you will only be asked to list your children. If you said you are BOTH in a marriage/committed relationship and have children, I will ask you to fill out sections on both.What is your spouse's name?* Their Age?* Their Occupation?* Children of your union*Please use the icon to the right to add a new line for each childAge of childSex of childOccupation Add RemoveDoes you have any children from another union?* Yes No List the children of your other union(s)*Please use the icon to the right to add a new line for each childAge of childSex of childOccupation Add RemoveDoes your spouse have any children from another union?* Yes No List the children of your spouse's other union(s)*Please use the icon to the right to add a new line for each childAge of childSex of childOccupation Add Remove Emergency ContactsEmergency Contact #1*NameRelationshipAddressCell NumberWork NumberHome NumberDoes this person work at the MICO?* No Yes Department* Emergency Contact #2*NameRelationshipAddressCell NumberWork NumberHome NumberDoes this person work at the MICO?* No Yes Department* Sign and SubmitJust one final step remains. Please use an appropriate input device (finger, stylus, mouse) to draw your signature in the space provided. When you sign this document, it will represent an agreement between us.Your Signature*EmailThis field is for validation purposes and should be left unchanged.
