APPLICATION FOR COUNSELING

Please answer all questions to the best of your knowledge. A separate Consent to Counsel form will be required for submission at the end of the form. You can find that here.

APPLICATION FOR COUNSELING

Please answer all questions to the best of your knowledge. A separate Consent to Counsel form will be required for submission at the end of the form. You can find that here.

APPLICATION FOR COUNSELING

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PERSONAL DATA INVENTORY

First name

Last name

Phone

Address

Occupation

Sex

Weight

Height

Age

Marital Status

Education

How did you hear about us?

HEALTH INFORMATION

Rate Your Health:

List all important present or past illnesses, injuries, or handicaps:

Have you ever used drugs for other than medical purposes? If so, which ones?

Current medications:

Have you ever had a severe emotional upset (outburst of anger, slamming doors, punching walls, etc.)? If so, describe the event. How often do these happen? When is the last time you had one?

RELIGIOUS BACKGROUND

Name of your present church and their denomination:

Are you a member of your present church?

How often do you attend church each month?

Religious background of spouse (if married):

List all previous religious affiliations and denominations:

Have you been baptized?

Who is God?

Do you pray to God?

Do you have full assurance of your salvation? Why or why not?

Do you believe you can lose your salvation?

Do you believe the Bible is inspired by God, inerrant, infallible, and sufficient for all things pertaining to life and godliness?

How many days each week do you read the Bible?

Do you have regular family time with God in the home?

Note any changes in your spiritual outlook.

LEGAL AND COUNSELING INFORMATION

Do you have an attorney? If so, please give name and phone number.

Have you ever had psychotherapy or counseling before? If so, list counselor/therapist information, dates, and type of therapy received.

What was the outcome of previous psychotherapy/counseling sessions?

Have you ever felt like people were watching you?

Have you ever had hallucinations? If so, describe what you saw and heard. List dates.

Do you have problems sleeping?

Do you smoke? If so, describe frequency.

Do you drink alcoholic beverages? If so, describe frequency.

How much caffeine do you consume each day?

List the fears you have.

MARRIAGE AND FAMILY INFORMATION

Describe your upbringing and your current relationship with your family:

Describe your relationship with your spouse, if applicable:

Describe your relationship with your children, if applicable:

PURPOSE FOR COUNSELING

What, from your perspective, is the primary problem/issue that brings you here for counseling?

What have you done about it? What do you hope we can do about it?

Please sign and upload Consent to Counsel form here:

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Please answer all questions to the best of your knowledge. A separate Consent to Counsel form will be required for submission at the end of the form. You can find that here.