Fullerton College Health Services

Counseling Intake Form

NAME:Angela Maria Zuluaga BIRTH DATE: AGE:

STUDENT ID NUMBER: 00339486 SEX: M ✔ F Other
HEALTH INSURANCE: I don’t have MARITAL STATUS: divorced
ANY PREVIOUS COUNSELING HISTORY? ✔ Yes No
LIST OF CURRENT MEDICATIONS:
DO YOU HAVE A CONSERVATOR?
NAME AND CONTACT OF CONSERVATOR:

ETHNICITY Native American Filipino

Asian/Pacific Islander ✔ Hispanic/Latino
Black White
Other:

STUDENT PROGRAM: SOURCE OF REFERRAL: CHILDREN:

A.A. Degree Self No
Vocational Education Friend/Family Yes
Major: Medical Staff Number:
Number of Units:8 unit Teacher/Staff Living at home:
Semester:

BRIEF DESCRIPTION OF THE PROBLEM:

my problems is that they are going to put my house in forclouse and Iam desperate I don’t know what to do I don’t know what to do and and I don’t wnat tomiss my classes

PLEASE CHECK ALL THAT APPLY:

Current thoughs of harming yourself Current thoughts of harming others
Current suicidal thoughts None apply

Angela Maria Zuluaga 03/30/2022

Student Signature Date

MentalHealth/CounselingIntakeForm Digital 8/23/2020