Name:
*
First Name
Last Name
Email:
Best Number to reach you:
(###)
###
####
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate:
*
MM
DD
YYYY
Sex:
Age:
Marital Status:
Single
Engaged
Married
Separated
Divorced
Remarried
Widow
Education:
Elementary
High School
GED
College
Graduate
What is your degree in:
Other Training (List Type and Years):
Hobbies:
Referred to us by:
Relationship to the person who referred you:
If you were raised by anyone other than your own parents, briefly explain::
How many siblings do you have?
Please state if brother / sister is older or younger
Name of Spouse:
First Name
Last Name
Spouse's Address if different:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Spouse's Occupation:
Spouse's Phone:
(###)
###
####
Spouse's Age:
Religion:
Education:
Does your spouse know you're coming for counseling?
Is your spouse willing to come to counseling?
Have you ever been separated?
If the answer above is YES, then please put the dates you were separated:
Husband's age when you were married:
Wife's age when you were married:
Wedding Date:
MM
DD
YYYY
How long did you know your spouse before marriage?
Length of steady dating with spouse:
Length of engagement:
Give brief information about any previous marriages:
Please give information about your children (NAME, AGE, SEX, LIVING, EDUCATION, MARITAL STATUS):
Have you ever had a severe emotional upset?
Have you ever had any psychotherapy or counseling before?
If you answered yes to the question above, please list counselor or therapist and dates:
What was the outcome?
Check off any of the following words which best describe you now:
*
At any time have you felt people were watching you?
*
At any time have you Had difficulty recognizing faces?
*
At any time have you been unable to judge distance?
*
At any time have you had visual hallucinations?
*
At any time have you had auditory (hearing) hallucinations?
*
Please list any fears you may have:
Have you ever been arrested?
*
If arrested, please give a brief explanation:
Approximately how many hours of sleep do you get each night?
When do you go to sleep at night?
When do you get up?
Rate your health:
Very Good
Good
Average
Declining
Your approximate weight:
Your approximate height:
Weight changes recently (Gained / Lost) How much?
List all important present and past illnesses, injuries, or handicaps:
Date of last medical examination:
MM
DD
YYYY
What was the report?
Name of your physician:
Address of your physician:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you presently taking medication?
List Medications:
Have you used drugs for other than medical purposes?
Please list drugs you've taken for reasons other than medical use:
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?
Denominational preference:
What church do you attend?
City:
Who is your pastor?
May we contact your pastor for background information?
What is the number of church services you attend per month?
1
2
3
4
5
6
7
8
9
10
10+
Church attended in childhood:
Have you been baptized?
Religious background of spouse:
Do you believe in God?
Do you pray to God?
Have you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?
Suppose you died today and God asked you “Why should I let you into my heaven?” What would you say?
Are you saved through Jesus Christ?
*
How much do you read the Bible?
Explain any recent changes in your religious life, if any?
Briefly explain the issues you are struggling with?
Briefly explain what you have done about it?
Briefly explain what you want us to do? (What are your expectations in coming here?)
Briefly explain what brings you here at this time?
Is there any other information we should know?
I hereby certify that the above statements are true and correct to the best of my knowledge. (Type your name below as your certified digital signature):
Today's Date:
MM
DD
YYYY
