Counseling Form

Best Method of Contact
Phone Call
Email

Country

City

State

Date of Birth

Gender
Male
Female

Marital Status
Single
In a Relationship
Married
Separated
Divorced
Widowed

Education (last year completed)

Rate Your Health
Very Good
Good
Average
Declining

List all important present or past illnesses/injuries/disabilities:

Are you presently taking medication?
Yes
No

Please list current medications:

Have you ever used drugs for other than medicinal purposes?
Yes
No

If applicable, please list drugs used for other than medicinal purposes:

Date most recently used:

Have you ever experienced severe emotional trauma?
Yes
No

If so, explain:

Have you ever been arrested?
Yes
No

Have you recently suffered the loss of someone who was close to you?
Yes
No

If so, explain:

Have you recently suffered a loss from serious social, business or other reversals?
Yes
No

If so, explain:

Do you consider yourself a religious person?
Yes
No
Not sure

Do you believe in God?
Yes
No
Not sure

Do you question your salvation?
Yes
No
Not sure what you mean

Do you pray to God?
Often
Sometimes
Rarely
Never

How often do you read the Bible?
Often
Sometimes
Rarely
Never

Do you have a regular daily devotion?
Yes
No

Has there been any recent changes in your religious life?
Yes
No

If so, explain

Have you ever had any psychotherapy or counseling before?
Yes
No

If so, what was the outcome?

Spouse's First Name

Spouse's Last Name

Spouse's Phone Number

Spouse's Occupation

Spouse's Age

Spouse's Education (in years)

Spouse's Religion

Is your spouse willing to receive counseling?
Yes
No
Not sure

Have you ever been separated?
Yes
No

If so, when?

Date of marriage

Husband's age when married

Wife's age when married

Give brief information about any previous marriages, if applicable:

Use this space for name/age/sex/education/marital status/living status for each child. Please mark an (*) by any child from a previous marriage or other relationship.

Briefly describe yourself:

Please describe the issue(s) that have caused you to seek counseling:

What steps have you taken to address the problem(s):

How do you feel we can help you with your situation:

What are you expectations for receiving counseling:

What, if anything, do you fear:

Is there any other information we should know:

What day would work best for your appointment? (Appointments available from 8:30am - 5pm)
Monday
Tuesday
Wednesday
Thursday