Counseling Services At The Mu Career Center Client Intake Form
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Date of Intake
Counseling Services at the MU Career Center
MU Career Counselors offer a holistic counseling approach and are available to
discuss social, emotional, and personal aspects of your academic major and career decisions.
Name (And Phonetic Spelling) ________________________________________________________________________
Address
___________________
City
State
Zip
Age
Gender
Race/Ethnicity
Sexual Orientation (check one):
Heterosexual
Bisexual
Pansexual
Lesbian
Questioning
Queer
Gay
Asexual
Other: ________________
Relationship status:____________________________________________________________________________________
What social or cultural identities would you like considered in your career counseling experience?
___________________________________________________________________________________________________
Have you used the Career Center before?
Yes
No If so, why? ____________________________________________
Contact Information
Please check any and all acceptable forms of communication, if we need to contact you (for example, your counselor is
sick and needs to reschedule.) Note: we will need your permission below to contact you.
Email address:
Initial here
Phone Number (please check which is preferred):
Cell (
) ____________________
Initial here __________
Work (
) ___________________
Initial here __________
Home Phone (
) _____________
Initial here __________
May we leave a message and indicate we are calling from the MU Career Center?
Yes
No
Initial here __________
MU Career Center Intake October 2017
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Parent category: Business