College Student Stress and Anxiety Intake Form

Personal Information

Full Name Age Student ID Email Address Year in School Freshman Sophomore Junior Senior Graduate Major/Area of Study

Current Stress & Anxiety

How would you rate your current stress level? None Mild Moderate Severe How would you rate your current anxiety level? None Mild Moderate Severe Please describe any symptoms you are experiencing

Potential Stressors

Academic Stress (classes, exams, assignments) None Some Significant Personal Relationships None Some Significant Family Issues None Some Significant Financial Concerns None Some Significant Other stressors you'd like to mention

Coping & Support

What coping strategies do you currently use? Who do you turn to for support?

Additional Comments

Is there anything else you'd like to share?