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STUDENT INFORMATION Section 2 (Kapiolani Community College)

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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
kapkaau@hawaii.edu
STUDENT INFORMATION – Section 2
The following information will help us to serve you better. This information that you are sharing will be considered part of your
confidential mental Health & Wellness Office record and treated with confidentiality. Please complete all sections of the form to the
best of your knowledge.
Today’s Date: (MM/DD/YYYY) ____/____/____ UH Student ID:___________
Date of Birth (MM/DD/YYYY): ____/_____/_____
Last Name: _________________________ First Name: __________________________________ M.I.: _____
Gender: □ Male □ Female □ Non-binary □ Prefer not to self-describe □ Prefer not to say
UH Email: ____________________ @hawaii.edu
*Please note that email is not considered confidential communication
LIVING SITUATION
Relationship Status: □ Single □ Married □ Partnered □ Divorced/Separated □ Widow □ Other
Living Arrangements: □ Alone □ Roommate(s) □ Partner/S.O. □ Parents □ Children, Age(s)? _____ _____
How long have you lived at your current local address? (mo/yr)
How long have you been on Oahu, HI?
Where were you born? Raised?
RACE/ETHNICITY
□Native Hawaiian □Native American □Caucasian □Asian American □African American □Latino
□Multi-Ethnic □Other: ____________________
SEXUAL ORIENTATION
□Straight □Lesbian □Gay □Bisexual □Questioning □Prefer not to answer
RELIGIOUS/SPIRITUAL PREFERENCE
□Agnostic □Atheist □Buddhist □Catholic □Christian □Hindu □Jewish □Muslim □No preference
□Other
ACADEMIC INFORMATION
Major (if declared): __________________________ Status: □Full Time □Part Time
Involvement with Student Organizations: □Yes □No
*If yes, please list: _______________________________________________________________________
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EMPLOYMENT
Are you currently employed? □Yes □No If yes, □Full Time □Part Time
DISABILITY
Are you registered with the Disability Support Office at WCC, as having a documented and diagnosed
disability? □Yes □No
If yes, please indicate which category of disability services you are registered for (check all that apply):
□Deaf or Hard of hearing □Learning Disorders □Attention Deficit/Hyperactivity Disorders
□Mobility Impairments □Neurological Disorders □Physical/Health Related Disorders □Visual Impairments
□Psychological Disorders □Other: __________________________________
MILITARY
Are you currently in the military? □ Yes □ No
If yes, which branch do you serve? □ Air Force □ Coast Guard □ Army □ Navy □ Marines
National Guard? □ Yes □ No
Have you ever served in any armed force? □ Yes □ No If yes, which branch? _____________________
Has your military career included any exposure to any traumatic or highly stressful experiences that continue
to bother you? □Yes □No
PREVIOUS BEHAVIORAL HEALTH SERVICES
Have you ever participated in professional counseling in the past? □ Yes □ No
If yes, where? _____________________ When? ____________________ With whom? __________________
Reason for counseling: ______________________________________________________________________
HEALTH INSURANCE
Do you have health insurance? □ Yes □ No
Who is your health insurance provider? _______________________________________________
*please note insurance is not necessary for services through the Ka’au Program.
HEALTH
Are you currently (or within the past year) under the care of a medical doctor? □ Yes □ No
If yes, for what condition? ____________________________________________________________________
Do you have any other significant medical condition? □ Yes □ No
Have you been hospitalized for mental health concerns? □ Yes □ No
If yes, where? _______________________________ When? __________________________________
Are you currently prescribed any medication? □ Yes □ No
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If yes, please list medication(s): ________________________________________________________________
Are you presently receiving counseling/psychiatric services from another provider or agency? □Yes □No
If yes, where? _________________________________ Name of provider? _____________________________
Overall, do you consider yourself a healthy person? □Yes □No
ALCOHOL & DRUG USE
Have you ever received treatment for alcohol and/or drug use? □Yes □No
If yes, where? _________________________ When? ______________________________________________
Over the last two weeks, how many times have you had five (5) or more drinks* in a row?
*drink is defined as a bottle/can of beer, glass of wine, wine cooler, a mixed drink, or a shot of liquor)
□ None □Once □Twice □3 to 5 times □6 to 9 times □10 or more times
Over the last two weeks, how many times have you smoked marijuana?
□ None □Once □Twice □3 to 5 times □6 to 9 times □10 or more times
Please check any drugs you have ever used:
□None □Cocaine/Crack □Ecstasy □Spice □Bath Salts □Methamphetamine □Inhalants
□Prescription drugs □LSD □PCP □Other
GENERAL INFORMATION
Do you represent the first generation in your family to attend college? □Yes □No
How would you describe your financial status right now?
□Always stressful □Often stressful □Sometimes stressful □Rarely stressful □Never stressful
How would you describe your financial situation while growing up?
□Always stressful □Often stressful □Sometimes stressful □Rarely stressful □Never stressful
Indicate how much you agree with these statement:
“I get the emotional help and support I need from my family.”
□Strongly agree □Somewhat agree □Neutral □Somewhat Disagree □Strongly Disagree
“I get the emotional help and support I need form my social network.”
□Strongly agree □Somewhat agree □Neutral □Somewhat Disagree □Strongly Disagree
“I generally feel good about myself and believe I am worthy.”
□Strongly agree □Somewhat agree □Neutral □Somewhat Disagree □Strongly Disagree
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___________________________________________ _______________________
“I generally feel safe about where I live and who I live with.”
□Strongly agree □Somewhat agree □Neutral □Somewhat Disagree □Strongly Disagree
“I generally don’t worry about where I will be living month to month.”
□Strongly agree □Somewhat agree □Neutral □Somewhat Disagree □Strongly Disagree
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.
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STUDENT INFORMATION Section 2 (Kapiolani Community College)

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Completed 3 February 2021

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