Please Enter the name of the counselor to whom you have been assigned. If you have not been assigned a counselor, please enter N/A.
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Name
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First Name
Last Name
Email Address
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Phone Number
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Sex, Age, Date of Birth
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Occupation
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Marital Status
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Education (Please enter highest graduating status, i.e. High School, etc.)
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Referred here by:
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Rate Your Physical Health
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Height
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Weight
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Weight Loss or Gain (Please specify)
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List all important past or present illnesses, injuries or handicaps.
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Date of Last Examination
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MM
DD
YYYY
Results of Last Examination
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Physicians Name
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Have you ever had severe emotional upset?
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Have you ever had a problem with drug or alcohol abuse?
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Have you seen a psychologist, psychiatrist and/or a counselor?
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If yes, please list counselor and/or therapists and dates:
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Are you willing to sign a release of information form so that your counselor may write for helpful social, psychiatric, or medical report?
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Have you ever been arrested? If yes, for what reason?
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Have you ever used drugs for anything other than medical purposes?
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Are you currently taking any medication?
Prescribed?
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Who has issued your prescriptions?
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Are you taking over the counter medications? If so, which medication and what dosage?
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Church you attend (if any):
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Are you the member of a church?
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If yes, what church?
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Please provide the Pastor's name and Phone Number:
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Church attendance per month
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Church attended in childhood:
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Have you been baptized?
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If married, what is the religious affiliation of your spouse?
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Are you saved?
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How often do you read your Bible?
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Explain any significant religious changes in your life:How would you describe
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How would you describe your personal relationship with Christ?
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Name of Spouse
Address 1
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
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Age of Spouse
Would your spouse be willing to come in for counseling, if needed?
Have you ever been separated? If so, please include dates of separation.
Have either of you ever filed for divorce? If so, when?
How long did you know one another before you were married?
Is this your first marriage? If no please briefly explain previous marriages.
Please include information about your children (Age, Sex, Living at Home):
