Counseling & Student Development Center - James Madison University

 

Enrollment Form

New Student Support Program

 

Please fill out the form below as completely as possible. Your responses will be submitted to a counselor at the Counseling Center via email. We cannot

guarantee the security of email transmissions; however, once your form is received at the Counseling Center, it will become a confidential record.

 

This form is being completed by:
If you are not the student, please provide your name:

Student Information
 

First Name

Last Name

Student ID #
( If known)

Permanent Address:      
Email Address:
Pref Phone Num:
 
     
Date of Birth:

University Status:

Gender:

Housing Type:

Ethnicity:  
 


Physical/Mental Health History
 

Please list any existing health conditions/concerns:

Please list any current medications and dosage levels:

Please list any diagnosed disabilities:

Have you ever received treatment from a counselor, psychologist, or psychiatrist? 

If yes, please list when, the approximate number of sessions, and for what reasons:

If you are currently under the treatment of a counselor, psychologist, or psychiatrist, please provide the name and contact
information for this individual(s):

  Therapist 1 Therapist 2 Therapist 3
Name
Address
 
 
Phone #

Will this individual(s) be providing the Counseling Center with information about your treatment?

If yes, please provide him or her with the following contact information for our office:

Counseling Center
Attention: Clinical Director
MSC 0801
James Madison University
Harrisonburg, VA 22807

Phone: (540) 568-6552
Fax: (540) 568-8096

Have you ever been prescribed medication for psychological reasons?

If yes, please list the reasons and the type(s) of medication:

Have you ever been hospitalized for psychological reasons?

If yes, when, for how long, and for what reasons:

Are you aware of any alcohol and/or drug abuse in your family?

If yes, please describe:

Are you aware of any psychological difficulties in your family?

If yes, please describe:

From your perspective, what will you need to do to make a successful transition to college life at JMU?

 

Would you like to participate in the New Student Support Program?

 

James Madison University
PUBLISHER: Counseling Center, MSC 0801, Harrisonburg, VA 22807 - PHONE: (540) 568-6552 - FAX: (540) 568-8096
 
Last Modified: 3/6/2014