Counseling Intake FormPlease be sure you have read all the information prior to completing.This document is valid for six months. Please complete if you are a return counselee and it has been six months since your last session. Name * First Name Last Name What is your age? * If you are a minor, name of parents/guardian * Email * Phone * (###) ### #### May we leave a message? * Yes No Address Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female Tell us about your occupation. * Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Phone * (###) ### #### What type of counseling are you requesting? * Premarital Marriage Individual Family Grief If marriage or premarital counseling, name your spouse or fiance'. * Your spouse or fiance' must complete intake form separately. Are you taking any prescription medication? If yes, please list. * If not currently taking prescriptions, have you ever been prescribed medication to treat a mental health issue? If yes, please list. * How would you describe your overall general physical health? * How often do you exercise? How is your sleep? Do you have any mental health related concerns (anxiety, depression, OCD, bi-polar, etc,)? * Do you struggle with suicidal thoughts? * Describe your current struggle and why you are seeking counseling? * What have you done about your struggle? Please provide any family history that might be pertinent to your reason for seeking counseling. List anything not covered here. Are you available for evening appointments? * Yes No Would you prefer in-person or over a virtual call? * In Person Virtual (ex. ZOOM) What church do you attend? What is your ministry involvement? How many times per month do you attend? Have you received Jesus as your personal Savior? * Yes No Is there anything else you'd like to share about your availability? Were you referred? Please list name. Have you read our intake information and agree to all terms , policies, and information listed? * Yes No Thank you!
