Ka’au Program for Student Mental Health & Wellness
Iliahi 117/118 in TRIO Center
4303 Diamond Head Road
Honolulu, HI 96816
Ph: (808) 734-9585
The following information will help us to serve you better. This information that you are sharing will be considered part of your
confidential Ka’au Program record. Please complete Section I prior to your initial appointment.
Today’s Date: (MM/DD/YYYY)
UH Student ID:
Date of Birth (MM/DD/YYYY):
Last Name: _________________________ First Name: __________________________________ M.I.: _____
Preferred Name: ___________________
Gender: Male Female Non-binary Prefer not to self-describe Prefer not to say
Home Phone: _______________________ Is it ok to call and leave a message? Yes or No
Cell Phone: Is it ok to call and leave a message? Yes or No
Is it ok to TEXT to your mobile phone? Yes or No
UH Email: ____________________ @hawaii.edu
*Please note that email is not considered confidential communication
LOCAL ADDRESS MAILING ADDRESS (if different from above)
1. Name: _______________________________ Phone: _______________________
Relationship: __________________________ Alt. Phone: _______________________
2. Name: _______________________________ Phone: _______________________
Relationship: __________________________ Alt. Phone: _______________________
How were you referred to the Mental Health & Wellness Office?
□ Self □ Instructor □ Faculty/Staff □ Friend □ Academic Advisor □ Other: _________________
Please briefly describe you reasons for seeking mental health & wellness support today:
I certify that the information provided here is true to the best of my knowledge.
___________________________________________ _______________________
Name Date
Mahalo for taking the time to complete Section I of this form.