Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Birth Date
MM
DD
YYYY
What services are you interested in?
Do you prefer online counseling over onsite, or are you open to either?
How would you like to receive appointment reminders? Would you allow us to send you text messages and emails for reminders, scheduling, and appointment-related updates as needed?
This is invaluable in helping us communicate efficiently. However, we will only use these methods when necessary and will never share your information with anyone else.
If you agree, please check the boxes below. If at any point after counseling begins you would like to update your communication preferences, your counselor can adjust them accordingly.
Our goal is to facilitate your counseling without unnecessary delays.
Gender
Marital Status
Anything else you would like us to know?
*
Spouse's Name (if applicable):
Children's Names and Ages (if applicable):
Who is the counseling for?
Self, Both me and my spouse, my child, etc...
Occupation
How did you hear about us, or who referred you? Which of our counseling centers are you looking to schedule with? (Please give the specific name)
What times are you best available Monday through Friday?
Do you have any physical or medical conditions?
If so, please explain.
Do you take any medications? *
If so, please explain.
What church do you regularly attend? *
If so, please explain.
Are you a member? In what ways are you involved in this church?
If you were to die tonight and stand before God and He asked you why He should permit you to enter heaven, what would you answer?
Who are your two closest friends and why?
Do you have a close Christian friend who, if needed, could come with you to the counseling center for support, encouragement, and accountability between sessions?
Have you received counseling in the past? Who, when, and for how long? Can you summarize what they believed the main problem to be and what they told you to do about it?
What is the main problem/trouble as you see it? (i.e. What needs to change?) How long has this been going on?
For this form, this only needs to be a brief description.
What things do you think have contributed to the problem/trouble? Do you believe you have in some ways contributed to the problem/trouble?
For this form, this only needs to be a brief description.
Please describe anything you have done about this problem so far. What were the results?
What would you like us to do?
