Counseling - NYC CAMPUS | NYFA Student Hub

Campus *

Los Angeles

New York

South Beach

Name *

Date of Birth *

Month

Day

Year

Phone *

Email *

In case of emergency *

Current year and program *

Ethnicity *

Relationship status *

Current living situation *

Please describe your current concerns, challenges or symptoms? *

Who referred you to counseling? *

Have you had previous counseling (If so, please list when and with whom)? *

Please list any current and or past medication within the past two years (please include dosage, if and when possible) *

Please list family members with any current or previous emotional or physical health concerns/challenges *

Current strengths/healthy coping *

Moods/Behaviors

Other moods/behviors

School Concerns

Other School Concerns

Relationships

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Home Concerns

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