ࡱ> c bjbjNN 4$i$inX 8Ot'"{{{&&&&&&&)L,&{Y"{{{&.'###{^8&#{&###)E#s&D'0t'#-!-#-#{{#{{{{{&&"{{{t'{{{{-{{{{{{{{{ Y y: First and Last Name: Preferred Name and Pronouns:Age:DOB:Local Address: Home Address (if different from local):Cell Number:Permission to call and leave message? % Y % NWork Number: Permission to call and leave message? % Y % NHome Number:Permission to call and leave message? % Y % NEmail: Email/Text Consent? % Y % N Preferred way to be contacted: % Cell % Text % Work % Home % Email Email correspondence is NOT considered a confidential medium of communication. Gender Identity (M, F, Trans, Other):Ethnicity: Sexual Identity (heteo-, gay, queer, pan, other): Relationship Status: % Single % Partnered % Married % Separated % Divorced % Widowed % Other ___________Current Partner s Name & Length of Relationship:Rate Relationship Satisfaction: (1 = Not at all satisfied) 1 2 3 4 5 6 7 8 9 10 (10 = Very Satisfied)Religion/Spirituality: Importance of Religion/Spirituality (Use 1  10 scale):  UTHSC College: UTHSC Program/Degree:UTHSC Grad. Year:Are you employed? % Y % NIf yes, # of weekly work hours: Employer:Have you served in the military? % Y % N Briefly describe your reason(s) for seeking therapy:   Name AgeRelationship to youSubstance Misuse HistorySuicidality HistoryPsychiatric HistoryAbuse History (verbal, physical, sexual)% Y % N% Y % N% Y % N % Y % N % Y % N% Y % N% Y % N% Y % N% Y % N% Y % N% Y % N % Y % N % Y % N% Y % N% Y % N % Y % N % Y % N% Y % N% Y % N % Y % N % Y % N% Y % N% Y % N% Y % N% Y % N% Y % N% Y % N % Y % N  PERSONAL HEALTH INFORMATION Mental Health:Chronic/Significant Concerns or DiagnosesDiagnosis DateBy Whom or WherePhysical Health:Chronic/Significant illness, disabilities, medical conditionsDiagnosis DateBy Whom or WherePsychiatric Providers Name and Contact Information:Primary Care Providers Name and Contact Information: Rate Sleep, Diet, Exercise and Support-Connection using the scale:Current sleep habits (1 = Poor) 1 2 3 4 5 6 7 8 9 10 (10 = Excellent)Current eating habits (1 = Poor) 1 2 3 4 5 6 7 8 9 10 (10 = Excellent)Current exercise habits (1 = Poor) 1 2 3 4 5 6 7 8 9 10 (10 = Excellent)Current social connection (1 = Poor) 1 2 3 4 5 6 7 8 9 10 (10 = Excellent)For ratings less than 5, explain briefly: List current self-care behaviors/ hobbies/interests that you engage in and frequency per week:  Traumatic Event Exposure (personally, or vicariously)SafetyStrengths & Supports ___ None; Denied___ Thoughts of suicide, current ___ Family support___ Childhood emotional abuse___ Thoughts of suicide, past ___ Religious/Spirituality___Childhood sexual abuse___ Plan for suicide ___ Social support system___ Sexual assault/violence___ Intent for suicide ___ Exercise___ Physical attack___ Access to means for suicide___ Intimate Relationship stability___ Military combat___ Suicide attempt past or recently ___ Coping skills___ Domestic violence___ Thoughts of harming others ___ Intellectual/cognitive skills___ Serious accident___ Acted violently towards others ___ Socioeconomic stability___ Other ____________________________ Engaged in self-harm (cutting, etc.)___ Communication skills__ Arrested for a violent act___ Insight, maturity, judgment___ None; Denied___ Us  8 9 : ; ? F H V _ l v        4 6 8 T f Żŕŕűrh hMOJQJ^JhMOJQJ^Jht CJOJQJ^JhC_ht CJOJQJ^Jh ht OJQJ^Jh-$uOJQJ^Jhc`~OJQJ^Jht OJQJ^Jh h-$uOJQJ^Jh h2OJQJ^Jh2OJQJ^Jh h OJQJ^J)rvkd$$Iflo-l- t 6`T\0l-644 layt?t $$T\&`#$/Ifa$gd-$u: cH$ i$T\&`#$/Ifa$gd2kd$$IfloFF -8z  t 6`T\0l-6    44 layt?t : ; H  rr$$T\&`#$/Ifa$gd-$uvkd>$$Ifl-l- t 6`T\0l-644 layt?t   8 v__$$T\&`#$/Ifa$gdCkd$$Iflo0-84 t 6`T\0l-644 layt?t   & ( 8 : < @ B     ( * , 4 > @ B R T V ` b ĺyhc`~hc`~OJQJ^Jhc`~OJQJ^JaJhc`~CJOJQJ^JhC_hc`~CJOJQJ^Jh hc`~OJQJ^Jhc`~OJQJ^Jh h-$uOJQJ^Jht CJOJQJ^Jht OJQJ^JhMOJQJ^JhC_hMCJOJQJ^J/ @ v__$$T\&`#$/Ifa$gdc`~kdn$$Iflf0-84 t 6`T\0l-644 layt?t @ B b v__$$T\&`#$/Ifa$gdc`~kd $$Iflf0-84 t 6`T\0l-644 layt?t b d  tvxz|@DFHt~ù󯢓xgZPAZAhC_h'<CJOJQJ^JhGOJQJ^Jh3h'<OJQJ^J h'<h'<CJOJQJ^JaJ h'<h| CJOJQJ^JaJh| OJQJ^Jhwh| CJOJQJ^Jhwh| OJQJ^JhMOJQJ^Jhc`~OJQJ^JhwIhc`~CJOJQJ^J"hwIhc`~56CJOJQJ^Jhc`~56CJOJQJ^Jh hc`~OJQJ^Jb d xr$$T\&`#$/Ifa$gdc`~vkd$$Iflw-l- t 6`T\0l-644 layt?t xz|Fjjj$$&`#$/Ifa$gdw$a$gd vkdC$$Ifl-l- t 6`T\0l-644 layt?t FH>=$$&#$/$'<kd$$IflFz,|jb t 6`0H-6    44 lapyt?t <>@*2BFVZjn~*,.ڷڷhwh?t OJQJ^Jh?t OJQJ^JhGCJOJQJ^JaJ h'<h'<CJOJQJ^JaJhGOJQJ^Jhwh'<OJQJ^Jh'<CJOJQJ^Jh'<OJQJ^JhC_h'<CJOJQJ^Jh3h'<OJQJ^J2>$$&#$/$'<|kd$$Ifl,H- t 6`0H-644 lap ytc`~,mm$$&`#$/Ifa$gd'<|kd@$$Ifl,H- t 6`0H-644 lap yt'<,.Nmm$$&`#$/Ifa$gd?t |kd$$Ifld,H- t 6`0H-644 lap ytc`~$HLNPR^nprtķķķķppdppdhNCJOJQJ^JhC_hNCJOJQJ^Jh hNOJQJ^JhNOJQJ^Jh h'OJQJ^Jh'OJQJ^JhwIOJQJ^Jh hwIOJQJ^JhGOJQJ^Jh hMOJQJ^Jhwh?t OJQJ^Jh?t CJOJQJ^JaJh?t OJQJ^J'NPRprtjbKKKKK$$B&`#$/Ifa$gdwI$a$gd kd|$$Ifl0, t 6`0H-644 lapyt?t cL777$$B&`#$/Ifa$gdC$$B&`#$/Ifa$gdNkd2$$IflF /!Z-x #+ t 6`B0-6    44 layt'dfhjRK6666$$&`#$/Ifa$gdagdF"kd$$Ifl\ /!Z-x  + t 6`B0-644 layt'dfhjlnprtvxz|~&(PlùùùùùËhwICJOJQJ^JhC_hwICJOJQJ^J hwIhwICJOJQJ^JaJhwICJOJQJ^JaJhwIOJQJ^Jh hwIOJQJ^Jhm8h=jhm8UmHnHuhWh haOJQJ^JhF"hF"<2jlnrtvxz|~{{qqqqgqqq $a$gdW $a$gd $^a$gdWvkd $$IflXZ-- t 6`0-644 laytq (P$$q&`#$/Ifa$gd' $a$gdkd& $$Ifl ֞@ $, F t 6`q0-644 laytTs$$q&`#$/Ifa$gdwI    "$,.0246>@BDFHJLNPXZ\^`bjlnprt|~hwICJOJQJ^JhwIOJQJ^JhC_hwICJOJQJ^Jh hwIOJQJ^JQkd $$Ifl@֞@ $, F t 6`q0-644 laytTs"4F$$q&`#$/Ifa$gdwIFHkd $$Ifl@֞@ $, F t 6`q0-644 laytTsHJLN`r$$q&`#$/Ifa$gdwI kd $$Ifl@֞@ $, F t 6`q0-644 laytTs$$q&`#$/Ifa$gdwI  $&(*,.08:<>@BDFHJLTVXZ\^fhjlnpxz|~hwICJOJQJ^JhwIOJQJ^JhC_hwICJOJQJ^Jh hwIOJQJ^JQkd $$Ifl@֞@ $, F t 6`q0-644 laytTs,.@B$$q&`#$/Ifa$gdwI BDkdY$$Ifl@֞@ $, F t 6`q0-644 laytTsDFHJ\n$$q&`#$/Ifa$gdwI&(*,HJ¸Τhf4 OJQJ^Jhh wOJQJ^Jh wOJQJ^JhOJQJ^JhjOJQJ^Jh/GLhm8<hm8h hwIOJQJ^JhwICJOJQJ^JhC_hwICJOJQJ^JhwIOJQJ^J5kd0$$Ifl@֞@ $, F t 6`q0-644 laytTs$$q&`#$/Ifa$gdwI kd$$Ifl@֞@ $, F t 6`q0-644 laytTs*,J`L$Q&`#$/Ifgd wvkd$$Ifl,, t 6`Q0,644 laytwI$$Q&`#$/Ifa$gdwI$a$gd= $a$gd7kdo$$Ifl4[\X ,J* t 6`Q0,644 layt`$$Q&`#$/Ifa$gdwI .WX]_afgwxyz{|}~¸¸¸h`OJQJ^Jhf4 OJQJ^Jh wOJQJ^Jh hf4 OJQJ^Jhhf4 OJQJ^Jhh wOJQJ^Jh h wOJQJ^JA7kd8$$Ifl4\X , J* t 6`Q0,644 layt`$$Q&`#$/Ifa$gdwIN7777$$Q&`#$/Ifa$gdwIkd$$Ifl4\X , J* t 6`Q0,644 layt`N7777$$Q&`#$/Ifa$gdwIkd$$Ifl4\X , J* t 6`Q0,644 layt`N7777$$Q&`#$/Ifa$gdwIkd$$Ifl4\X , J* t 6`Q0,644 layt` XgxN7777$$Q&`#$/Ifa$gd wkdD$$Ifl4\X , J* t 6`Q0,644 layt`xyz{|}N7777$$Q&`#$/Ifa$gd wkd$$Ifl4\X ,J* t 6`Q0,644 layt`}~N7777$$Q&`#$/Ifa$gd wkd$$Ifl4\X ,J* t 6`Q0,644 layt`N7777$$Q&`#$/Ifa$gd wkd$$Ifl4\X ,J* t 6`Q0,644 layt`N7777$$Q&`#$/Ifa$gd wkdb$$Ifl4\X ,J* t 6`Q0,644 layt`N7777$$Q&`#$/Ifa$gd wkd+$$Ifl4\X ,J* t 6`Q0,644 layt`N7$$Q&`#$/Ifa$gd wkd$$Ifl4\X ,J* t 6`Q0,644 layt`  '13BCDELRX[`aejlmuwȺȺȬȬҕ}}}l^l^l^lh{CJOJQJ^JaJ h'<h{CJOJQJ^JaJh OJQJ^Jh hH6OJQJ^JhHOJQJ^Jh>}h>}OJQJ^Jh>}h>}>*OJQJ^Jh>}h{>*OJQJ^Jh{OJQJ^Jh>}OJQJ^Jh hrsOJQJ^Jh`OJQJ^Jh h`OJQJ^J$r$$Q&`#$/Ifa$gd wvkd$$Ifl,, t 6`Q0,644 layt`Cs$$Ifa$gdF"$a$gd=vkdN$$Ifl&,, t 6`Q0,644 layt`CD $$Ifa$gd lkd$$Ifl00*- t0-644 layt{   (*24<>FHPRZ\dfhprö͗hHOJQJ^Jh>}CJOJQJ^JaJ h'<h>}CJOJQJ^JaJh h`6OJQJ^Jh h`OJQJ^Jh>}OJQJ^Jh OJQJ^Jh{OJQJ^J h'<h{CJOJQJ^JaJh{CJOJQJ^JaJ-$$Ifa$gdF"lkdh$$Ifl00*- t0-644 layt  !;<=>GOQY[cemowyɻɻɻɻɻɻɻɻɻɻɻɻɻɻɻɻɻɻ癧h h>}6OJQJ^Jh OJQJ^JhHOJQJ^Jh>}CJOJQJ^JaJ h'<h>}CJOJQJ^JaJh h>}OJQJ^Jh>}OJQJ^Jh hH6OJQJ^J8 $$Ifa$gdF"lkd$$Iflu00*- t0-644 layt>} !$$Ifa$gdF"lkdz$$Ifl00*- t0-644 layt>}$$Ifa$gd lkd$$Ifl00*- t0-644 laytF"QRSTm ïïïïykyykyZ hTshc*CJOJQJ^JaJhhCJOJQJ^JaJhhOJQJ^JhoCJOJQJ^JaJ hTshhCJOJQJ^JaJh hhOJQJ^J&h 0hh5CJOJQJ\^JaJh 0hh5OJQJ\^JhF"hF"<h OJQJ^Jh h 6OJQJ^Jh h OJQJ^JQR$$Ifa$gd lkd$$Ifl00*- t0-644 layt RSTmwwwkTT$$&`#$/Ifa$gd 0 $$Ifa$gd 0$&`#$/Ifgd 0gdF"lkd$$IflX00*- t0-644 layt cL@LL $$Ifa$gd 0$$&`#$/Ifa$gd 0kd$$IflF-$$$ t 6`0l-6    44 layt 0,-HcL>LL$$Ifa$gd 0$$&`#$/Ifa$gd 0kd) $$IflF-$$$ t 6`0l-6    44 layt 0,-0GHILbcfxy| - . / 2 B C F j k n | } ~ !!!+!,!-!輫輫輫輫輫輫 hTshc*CJOJQJ^JaJh hhOJQJ^JhoCJOJQJ^JaJ hTshoCJOJQJ^JaJhhOJQJ^Jhc*CJOJQJ^JaJCHIcxycL>LL$$Ifa$gd 0$$&`#$/Ifa$gd 0kd $$IflF-$$$ t 6`0l-6    44 layt 0cL>LL$$Ifa$gd.F5$$&`#$/Ifa$gd.F5kdK!$$IflF-$$$ t 6`0l-6    44 layt 0 . cLLL$$&`#$/Ifa$gd.F5kd!$$IflF-$$$ t 6`0l-6    44 layt 0. / C j k } cL>LL$$Ifa$gd.F5$$&`#$/Ifa$gd.F5kdm"$$IflF-$$$ t 6`0l-6    44 layt 0} ~ cL@LL $$Ifa$gd 0$$&`#$/Ifa$gd 0kd"$$IflF-$$$ t 6`0l-6    44 layt 0 !!,!cL>LL$$Ifa$gd 0$$&`#$/Ifa$gd 0kd#$$IflF-$$$ t 6`0l-6    44 layt.F5,!-!Q!z!!cNB+$$&`#$/Ifa$gd 0 $$Ifa$gd 0$$&`#$/Ifa$gd 0kd $$$IflF-$$$ t 6`0l-6    44 layt 0-!0!P!Q!T!y!z!}!~!!!!!!!!!!!!!!!!!!Ƹƙ׌Ƹ{Ƹ׌qƸƸoqbXhs. OJQJ^Jh hoOJQJ^JUhoOJQJ^J h 0hhCJOJQJ^JaJh hhOJQJ^Jh 0CJOJQJ^JaJ hohhCJOJQJ^JaJhoCJOJQJ^JaJ hTshoCJOJQJ^JaJhhOJQJ^Jhc*CJOJQJ^JaJ hTshc*CJOJQJ^JaJ!!!!!cL@L $$Ifa$gd 0$$&`#$/Ifa$gd 0kd$$$IflF-$$$ t 6`0l-6    44 layt 0!!!!cL@L $$Ifa$gd 0$$&`#$/Ifa$gd 0kdB%$$IflF-$$$ t 6`0l-6    44 layt 0e of available services If you have received counseling or BH services at UTHSC or elsewhere in the past, specify when and with whom. If you are currently seeing another MH provider, specify with whom and the concern.If you have been to the ED or hospitalized for MH concerns, specify when, with whom and the concern. List All Medications (prescribed, OTC, supplements, etc.)Medication NameDosageReason takenStart DateAre you compliant with instructions for medication use? Yes or no If no, explain. Current Substance Use: USE OF ILLICIT OR ILLEGALLY OBTAINED SUBSTANCES DURING CLINICAL TRAINING IS PROHIBITED AND MUST BE REPORTED.Substance NameFrequency/amount of useDo you or others believe misuse is an issue with this substance?Yes or No% Y % N% Y % N% Y % N% Y % N In the event of an emergency whom may we contact? (Name, relationship and phone number) How did you hear about UCS Counseling Services & Behavioral Health? % Self % Friend/Colleague % College/Program % Faculty/Staff % Student Counseling % Website % Care Referral % Other __________________     UNIVERSITY COUNSELING & BEHAVIORAL HEALTH SERVICES  INTAKE FORM  PAGE \* MERGEFORMAT 2c[[DDD$$s&`#$/Ifa$gdw-$a$gd=kd%$$IflF-$$$ t 6`0l-6    44 layt 0$*DEFGHIѨyobobobXbbh?&&OJQJ^Jh hD#OJQJ^JhD#OJQJ^Jh h?&&OJQJ^Jh&h?&&5OJQJ\^Jh.F5OJQJ^Jhs. hs. <hh<hjOJQJ^JhOhw-OJQJ^Jh3#OJQJ^Jh hw-6OJQJ^Jh hw-OJQJ^Jhw-OJQJ^Jh`OJQJ^J"Err$$s&`#$/Ifa$gd3#vkdd&$$Ifl.Z-- t 6`s0-644 layt3#EFGHIvoh`K$$&`#$/Ifa$gdj$a$gd.F5gds. gdkd&$$Ifl{0 Z-vP t 6`s0-644 layt3#tttt$$&`#$/Ifa$gdjvkd'$$Ifl^-l- t 6`0l-644 layt?&&P;;;;$$&`#$/Ifa$gdjkd%($$Ifl\r$->p t 6`0l-644 layt?&&!"#8:> !" ̵̵̵̵̨̿̏hC_hH<CJOJQJ^JhH<OJQJ^Jh hq OJQJ^Jhq OJQJ^Jhq 5OJQJ\^Jh&hq 5OJQJ\^Jh h?&&OJQJ^Jh?&&OJQJ^Jh hD#OJQJ^J4P;;;;$$&`#$/Ifa$gdjkd($$Ifl\r$->p t 6`0l-644 layt?&&P;;;;$$&`#$/Ifa$gdjkd)$$Ifl\r$->p t 6`0l-644 layt?&&R====$$&`#$/Ifa$gdjkdV*$$Ifl\r$->p t 6`0l-644 layt?&&R====$$&`#$/Ifa$gdjkd +$$Ifl\r$->p t 6`0l-644 layt?&&!"R;&$$&`#$/Ifa$gdj$$&`#$/Ifa$gd?&&kd+$$Ifl\r$->p t 6`0l-644 layt?&&"#:v_$$&`#$/Ifa$gdq $$&`#$/Ifa$gdq tkd{,$$Ifl-l- t 6`0l-644 laytF"tttt$$&`#$/Ifa$gdq vkd-$$Ifl-l- t 6`0l-644 laytq  !"P;;;;$$&`#$/Ifa$gdq kd-$$IflE\\ 4&-  xT t 6`0l-644 laytH< $&(*,.0246>ھھھʹ|"<OJQJ^JaJhF"hH<OJQJ^JhF"hH<CJOJQJ^JhF"hq OJQJ^Jh.F5OJQJ^JhC_hH<CJOJQJ^Jh hq OJQJ^Jh&hq 5OJQJ\^JhH<OJQJ^JhH<CJOJQJ^J0,P;;;;$$&`#$/Ifa$gdq kdT.$$Ifl\\ 4&-  xT t 6`0l-644 laytH<,.024FP;;;;$$&`#$/Ifa$gdq kd/$$Ifl\\ 4&-  xT t 6`0l-644 laytH<FHJLN`P;;;;$$&`#$/Ifa$gdq kd/$$Ifl\\ 4&-  xT t 6`0l-644 laytH<`bdfPHH<< $$Ifa$gdF"$a$gd.F5kd0$$Ifl\\ 4&-  xT t 6`0l-644 laytH< $$Ifa$gdF"nkd@1$$Ifl*- t0-644 laBp ytF"04bf "$&(*,.02468:<>@BDF\pÿ~vkvh h CJaJhiCJaJh hwjhwUh h{*OJQJ^Jh hR4>*OJQJ^Jhs. hs. <h h6OJQJ^Jh hOJQJ^Jh.F5OJQJ^JhF"hq OJQJ^JhF"hH<CJOJQJ^JhF"hH<OJQJ^J' "$&(*,~~~wrwj$a$gd gdR4gds. $a$gd=$a$gd.F5nkd1$$Ifl*- t0-644 laBp ytF" ,0268<>BDFLx$a$gdm8$&`#$/a$gdm8$a$gdW$a$gdO:$a$$a$gd gd~(46DFL˾Ǫ~~~rfZ~~~Phm8OJQJ^JhWOJQJ^JaJh&k(OJQJ^JaJh&k(CJOJQJ^Jh OJQJ^Jh&k(hSOJQJ^Jh&k(OJQJ^J h&k(hWh=h%K`UjhO:UmHnHuhO:mHnHuhO:jhO:Uh8h h~CJaJh h CJaJh hO:CJaJhO:CJaJ Check all the issues/concerns that you believe apply to your current situation. ___ Academic Difficulty ___ Career Indecision ___ Alcohol/Drug ___ Anxiety ___ Body Image ___ Depression ___ Eating Disorder ___ Family ___ Financial ___ Grief ___ Imposter Syndrome ___ Memory ___ Perfectionism ___ Relationship ___ Sexual Violence ___ Sexual Identity ___ Stress ___ Trauma Rate the seriousness of the issues/concerns: (1 = Not at all serious) 1 2 3 4 5 6 7 8 9 10 (10 = Very Serious) x  04DHX\lpt콴h h{*OJQJ^Jh=h/GLh&k(hm8aJ h aJhm8CJOJQJ^JaJ h'<hm8CJOJQJ^JaJhaOJQJ^Jhm8OJQJ^Jh OJQJ^J$a$gd $a$gdW21h:pO:/ =!8"8#$%  $$If!vh#vl-:V lo t 6`T\0l-65l-yt?t $$If!vh#v8#vz #v :V lo t 6`T\0l-6585z 5 yt?t $$If!vh#vl-:V l t 6`T\0l-65l-yt?t $$If!vh#v8#v4:V lo t 6`T\0l-65854yt?t $$If!vh#v8#v4:V lf t 6`T\0l-65854yt?t $$If!vh#v8#v4:V lf t 6`T\0l-65854yt?t $$If!vh#vl-:V lw t 6`T\0l-6,5l-yt?t $$If!vh#vl-:V l t 6`T\0l-65l-yt?t $$If!vh#v|#vj#vb:V l t 6`0H-65|5j5bpyt?t $$If!vh#vH-:V l t 6`0H-65H-p ytc`~$$If!vh#vH-:V l t 6`0H-65H-p yt'<$$If!vh#vH-:V ld t 6`0H-65H-p ytc`~$$If!vh#v#v:V l t 6`0H-655pyt?t $$If!vh#vx #v##v+ :V l t 6`B0-65x 5#5+ yt'$$If!vh#vx #v #v#v+ :V l t 6`B0-65x 5 55+ yt'$$If!vh#v-:V lX t 6`0-65-ytq $$If!vh#v #v#v#vF#v#v:V l  t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v #v#v#vF#v#v:V l@ t 6`q0-65 555F55ytTs$$If!vh#v,:V l t 6`Q0,65,ytwI$$If!vh#vJ#v#v#v* :V l4[ t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#vJ#v#v#v* :V l4 t 6`Q0,6+,5J555* yt`$$If!vh#v,:V l t 6`Q0,65,yt`$$If!vh#v,:V l& t 6`Q0,65,yt`$$If!vh#v-:V l t0-6,5-ayt{$$If!vh#v-:V l t0-6,5-ayt $$If!vh#v-:V lu t0-6,5-ayt>}$$If!vh#v-:V l t0-6,5-ayt>}$$If!vh#v-:V l t0-6,5-aytF"$$If!vh#v-:V l t0-65-ayt $$If!vh#v-:V lX t0-65-ayt $$If!vh#v$:V l t 6`0l-6,5$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt.F5$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v$:V l t 6`0l-65$yt 0$$If!vh#v-:V l. t 6`s0-65-yt3#$$If!vh#vv#vP:V l{ t 6`s0-65v5Pyt3#$$If!vh#vl-:V l^ t 6`0l-65l-yt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#v>#v#v#vp:V l t 6`0l-65>555pyt?&&$$If!vh#vl-:V l t 6`0l-65l-ytF"$$If!vh#vl-:V l t 6`0l-65l-ytq $$If!vh#v #v #vx#vT:V lE t 6`0l-65 5 5x5TytH<$$If!vh#v #v #vx#vT:V l t 6`0l-65 5 5x5TytH<$$If!vh#v #v #vx#vT:V l t 6`0l-65 5 5x5TytH<$$If!vh#v #v #vx#vT:V l t 6`0l-65 5 5x5TytH<$$If!vh#v #v #vx#vT:V l t 6`0l-65 5 5x5TytH<$$IfB!vh#v-:V l t0-65-aBp ytF"$$IfB!vh#v-:V l t0-65-aBp ytF"x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH J`J ?&&Normal $a$CJ_HaJmH sH tH ^^ pq Heading 1$<@&"5CJ KH OJPJQJ\^JaJ `` pq Heading 2$<@&$56CJOJPJQJ\]^JaJDA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List nn = Table Grid7:V04@4 ~0Header  H$6/6 ~0 Header CharCJaJ4 @"4 ~0Footer  H$6/16 ~0 Footer CharCJaJLBL ~0 Balloon TextCJOJQJ^JaJN/QN ~0Balloon Text CharCJOJQJ^JaJ6U a6 :0 Hyperlink >*B*phcV/qV pqHeading 1 Char"5CJ KH OJPJQJ\^JaJ X/X pqHeading 2 Char$56CJOJPJQJ\]^JaJB' B S0Comment ReferenceCJaJ<< S0 Comment TextCJaJ:: S0Comment Text Char@j@ S0Comment Subject5\F/F S0Comment Subject Char5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  O4׹ӧCvHa01 %xz24ĥ=m X\(7Xjg !Ӆqd? cG7.`~w*?, 2 nN*"Fz_&n &\ F:l[+%f WWZ OOmmmp b -! !%*16<HLNRW_glu{~:  @ b xF>,NjFHBDx}C RH. } ,!!!E",F`, "#$&'()+,-./02345789:;=>?@ABCDEFGIJKMOPQSTUVXYZ[\]^`afhijkmnopqrstvwxyz|}Ogip!@ @ (  P   "? B S  ?H0(  - l*t "#%&i   #(,15;?IMRV[_eisw| r v   } "#%&33333333333333333333333333333333333333be~ &Q[giS]be~ &&'2<[iC'`;UVUGt =?t q f4 s. (o hp$H2oTSG#?&&'N'&k(\*{*s-/uH/g/n0Fs2R4.F5p\5O:H<'<0m@7A E}EAGwI\Kx#L/GLUvMOr{Q|WWXC_N_`%K`a/$aUchwhjp*j CjnkBlSnNWo2ppqrs-$uwcE|1~c`~9We LJNw ci u&G5E@W *s!GTsm8k@FY :}wS% K 0;<Ms8c*mN 2QD#@vvvvvvvv b@@@ @ @@@@@@4@@@@@@Unknown G.[x Times New Roman5Symbol3. .[x ArialC.,.{$ Calibri Light7..{$ Calibri5..[`)TahomaC. Aptos Display3. AptosA$BCambria Math"hxȇxȇf'L ( ,!820e3@P $P=2!xxav $UTHSC COUNSELING  ADULT INTAKE FORMDownsWilliams Collins, Kimberly Y Oh+'0 <H h t  (UTHSC COUNSELING ADULT INTAKE FORMDownsNormal Williams Collins, Kimberly Y2Microsoft Office Word@F#@Ӟ @ E@ EL ՜.+,D՜.+,< px  Heritage Schools, Inc. Document(  %UTHSC COUNSELING ADULT INTAKE FORM Title(T\ContentTypeId _activity,0x0101001D0ACE375C392A44881C1F97D678478F  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F҆)E Data N21Table-WordDocument4SummaryInformation(DocumentSummaryInformation8MsoDataStore @)E)EGVXG3LPP==2P)Ep)EItem  PropertiesJ3RO05EQQ==2 P)E])EItem  6Properties }ITXVLIZIQ==2P)E)EItem Properties O !"#$%'801-787-7735 This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. metaAttributes"/>DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qCompObj&r