Name
*
First Name
Last Name
Birthday
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Home Address (number, street, city, state, zip)
*
Occupation (including student, stay-at-home mom, retired, etc.)
Education
High School
Some college
Undergraduate Degree
Master's Degree
Doctorate
Trade School
Area of study
High School
Some college
Undergraduate Degree
Master's Degree
Doctorate
Trade School
Hobbies
How did you hear about our services?
Briefly describe your parents
Any siblings? If so, how many?
Any important family history to be aware of?
Any childhood traumatic events to be aware of?
Marital Status
Single
Dating
Married
Separated
Divorced
Divorced & Remarried
Widowed
Widowed & Remarried
Name of spouse/significant other
Do you have children? If so, what are their ages?
What is your current living situation?
Any important relationship information to be aware of?
Have you ever had therapy or counseling before?
Yes
No
What was the result of your counseling?
Describe your sleeping patterns
Describe your physical activity
Describe your eating habits
Are you on any medications? If so, what are they? For how long?
Have you had suicidal ideation in the past year?
Yes
No
How frequently do you consume alcohol?
Daily
Weekly
Occassionally
Very Rarely
Never
Do you smoke marijuana?
Yes
No
In the past five years, have you used illegal drugs or excessive prescription drugs? If so, what are they?
Have you ever been arrested? If so, what for?
Do you consider yourself to be a Christian?
Yes
No
Unsure
What church do you attend (if any)?
If you attend a church, are you involved in serving or groups? What are they?
Do you read the Bible? If so, how often?
How do you believe God views you at this moment?
Have there been any recent changes in your religious/spiritual life? If so, what?
What brings you to counseling? Please be specific about the problems you are experiencing.
What have you tried to do about the struggle(s)?
What are your hopes and goals for counseling?
Is there any other helpful information you think I should know?
Date
MM
DD
YYYY
