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.
I. Personal Information
Name*: Birthday*:A.D.Y-JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DECM-12345678910111213141516171819202122232425262728293031D
ID No.*: Gender*:*Male
Student ID*: Status*:-General Student Transferred Student International Student(Included OCS) Chinese Student Exchange Student Resource Room Student Division*:-Day Division Continuing Education Department Others
College*:-8College of Medicine 9College of Indigenous Studies 10Others Grade*:-Freshman Sophomore Junior Senior Others
Department*:-8Dep. of Biological Science and Technology 8Dep. of Health Management 8Dep. of Nutrition 8Dep. of Biomedical Engineering 8Dep. of Healthcare Administration 8Dep. of Nursing 8Dep. of Medical Imaging and Radiological Sciences 8Dep. of Physical Therapy 8Dep. of Occupational Therapy 8School of Chinese Medicine for Post Baccalaureate 8School of Medicine for International Students 10Others
Phone*: Address*: E-mail*:
Intimate Relationship: Married--Separated Divorce Remarry Widowed Unmarried--Cohabitation In a Stable Relationship Not In a Relationship
Family Relationship: Father*--Alive Deceased unknown Mother*--Alive Deceased unknown Parental Marital Status*--In Harmonious Relations Not Get Along Well Divorced
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*:-Initiative to Come Referred by Faculty Member/ Advisor Requested by Counseling and Guidance Section Suggested by Relevant Test Result Others
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:
3 Adjectives for introducing yourself:
Special experience in your life (birth, development, study, work...):
Time you free to talk*:
Week-MON TUE WED THU FRI-*0820-09100920-10101020-11101120-12101330-14201430-15201530-1620
Week-MON TUE WED THU FRI-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*:*Low
Please report your personal feeling and lifestyle over the past two weeks (including today).
1.Do you feel down recently?* *No
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*No
3.Do you eat more or less recently?* *No
4.Are you physically uncomfortable recently?* *No
5.Do you often absent from school recently?* *No
6.Do you have suicidal thoughts recently?* *No
degree(0:not at all~5:very often) Description:
7.Other phenomenon, please decribe it.
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* *Agree
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
義守大學 高雄市84001大樹區學城路一段1號 Tel: 886-7-6577711