Making a Counseling Appointment(Medical Campus)

The information is only used for counseling services. If you agree with it, please fill in the application form.

*is required.

 

I. Personal Information

Name*:             Birthday*:A.D.YMD

ID No.*:           Gender*:*

Student ID*:     Status*:     Division*:

College*:     Grade*:   

Department*:      

Phone*:             Address*:     E-mail*:

Intimate Relationship: Married-     Unmarried-

Family Relationship: Father*-     Mother*-     Parental Marital Status*-

                                   Older Brother-person(s)     Older Sister-person(s)     Younger Brother-person(s)     Younger Sister-person(s)

Emergency Contact:Person*-     Relationship*-     Contact Phone Number*-


II.Counseling Need Assessment

Reason for Counseling*:    

Issues*:*Self exploring Emotional Problem Career Development Romantic Relationship Interpersonal Relationship Family Academic Studies Others

Please give a brief description for your issues or problems:

Self Introduce:

     3 Adjectives for introducing yourself:

     Special experience in your life (birth, development, study, work...):

     Interpersonal profile:

     Learning profile:

Time you free to talk*:

     Week-*0820-09100920-10101020-11101120-12101330-14201430-15201530-1620

     Week-0820-09100920-10101020-11101120-12101330-14201430-15201530-1620

     Week-0820-09100920-10101020-11101120-12101330-14201430-15201530-1620

     【Please tick the convenient period as much as possible to improve the chances of success matchmaking】

Emergency of counseling need*:*


III.Self-reported Assessment

Please report your personal feeling and lifestyle over the past two weeks (including today).

1.Do you feel down recently?*      degree(0:not at all~5:fell very down)     Description:

2.Do you change your sleeping mode recently?* eg. hard to fall sleep, sleep more or less*     Description:

3.Do you eat more or less recently?* *     Description:

4.Are you physically uncomfortable recently?* *     Description:

5.Do you often absent from school recently?* *     Description:

6.Do you have suicidal thoughts recently?*     degree(0:not at all~5:very often)     Description:

7.Other phenomenon, please decribe it.

 

 IV.Informed Consent

Please carefully read through the Individual Counseling Agreement. No appointment is made unless you agree on the following terms and conditions. If you have any further questions or concerns, please feel free to contact the Counseling and Guidance Section. 

1.   Purpose: Counseling is a process that will help you to know and understand yourself. Through this self-discovery process, you will be able to come up with workable solutions for difficult situations and to change and grow toward a better life.

2.    Relationship between Counselor and you: Counseling is conducted based on a cooperative relationship. As you are the person who receives counseling, you have the right to decide on the priority of problems, how to cope with the problems, and the depth of the talks. More importantly, taking a sincere and positive attitude plays an important role to a successful counseling. 

3.    Service fee: The counseling service provided by the Counseling and Guidance Section is free of charge for all ISU students. 

4.    Counseling Appointment: 

A.   In principle, counselor will meet you once a week for 50 minutes unless there is other consideration. 

B.   In principle, the number of counseling is limited for 4-8times, if there is special need, continuing counseling is available. 

 

C.   Your counseling service will be cancelled if you (a) do not show up for your appointment without valid reason for twice or (b) absent from the appointment for three times continuously. 

5.     Cancelling an appointment: If you are unable to attend the counseling for any reason, please cancel or postpone the appointment by phone or in person at least one day beforehand. Please call the Counseling and Guidance Section at (07) 657-7711 ext. 2232 (Main Campus) or (07) 615-1100 ext. 3235 (Medical Campus).

6.      Confidentiality: Your personal information and counseling records will be kept confidentially and stored securely at the Counseling and Guidance Section. Only counselors and case administrator in Counseling and Guidance Section will access to your information. If your advisor or anyone applies for accessing to your personal information or counseling records, no information will be released without your prior consent. Confidentiality will be excluded in the following situations 

A.      You may threaten you or others’ life, freedom, property or safety.

B.       You are involved in a violation of law, e.g. Genetic Health Act, Domestic Violence Prevention Act, The Protection of Children and Youths Welfare and Rights Act, Sexual Assault Crime Prevention Act to name a few.

7.   Referral: Besides your consent or exception of above situations, your personal information and counseling records will be kept confidential and not released to anyone. But if you are referred by your parent, teacher or faculty, the Counseling and Guidance Section may inform the referring person of whether you will continue receiving counseling as well as the number of times you have received counseling.

8.   Terminating the Counseling: You have the right to terminate the counseling any time. Please conduct concluding counseling with your counselor before terminating the counseling.

 

9.    Supervision: To improve counseling effectiveness and service quality, counselors will receive an evaluation on a regular basis and have seminars on counseling process and skills.

 

I have already carefully read through the Agreement, and I* *  to receive counseling service from the Counseling and Guidance Section.

 

 

[Counseling and Guidance Section]  

Case Administrator/Counseling psychologist: Liao, Che-Hsin

Tel:(07) 615-1100 ext. 3235

E-mail: