First Name: *

Middle Initial:

Last Name: *

Legal Name:

If different

SUID# *

Date of birth

Email *

Phone

Pronouns

Address (If living off campus)

City

State/Province

Zip/Postal

Current Housing:

Residence Hall

Off Campus

Commute from Home (live with family)

Do you have a roommate?

Yes

No

Academic Status

Current GPA:

Number of credits enrolled this semester:

Major(s)

Are you working this semester?

Yes

No

Are you working on or off campus?

On campus

Off campus

Both

How many hours a week are you working? What is your job title?

Did you transfer from another institution?

Yes (which semester?)Yes (which semester?)

No

Do you have health insurance? If so, who is your insurer?

Racial/ Ethnic Background (Check All That Apply):

African-American/Black

American Indian or Alaskan Native

Asian American/Asian

Hispanic - Latino/a

Multi-racial

Native Hawaiian/Pacific Islander

White

Self-IdentifySelf-Identify

Country of origin

Are you an international student?

Yes

No

Referred by:

Current Activities

Community Based Learning (please specify)Community Based Learning (please specify)

SU Student Organization/Groups (please specify)SU Student Organization/Groups (please specify)

Athletics - Intramurals (please specify)Athletics - Intramurals (please specify)

Athletics - Varsity (please specify)Athletics - Varsity (please specify)

Volunteer Work (please specify)Volunteer Work (please specify)

Student Mentor (please specify)Student Mentor (please specify)

OtherOther

None

Current Stressors & Concerns

Please rate the intensity of your concerns for the following using a 0-10 rating scale.
0=not a concern 10=extremely concerned

Academic Career

Eating Concerns

Academic Performance

Family Concern/Problem

Alcohol

Financial

Anger

Grief

Anxiety/Stress

Self-Concept/Self-Esteem

Attention Difficulties

Conduct/Legal Issues

Depression/Feeling Unhappy/Sad/"The Blues"

Drugs

Relationship Issues (friend/roommate)

Romantic Relationship

Time management/study skills

Physical health

Motivation

College adjustment/loneliness/homesickness

Sleeping concerns

Safety

Reason for meeting with Case Management at this time *

Are you currently meeting with other Support Services (check all that apply)?

Counseling Center

Health Services

Academic Center for Excellence

Off Campus Mental Health Provider

Center for Race, Equity, & Identity

Office of Accessibility Services

Community AgencyCommunity Agency

OtherOther

Have you ever worked with one of these offices in the past?

Current Supports - Please note where you get support and help from in your life.

Do you have accommodations with the Office of Accessibility Services?

Yes

No

Any additional information that you would like us to be aware of: