Member Help Form
(Each person desiring counseling needs to fill out separate form.)
Select a date
Name
Email
Phone Number
(No Dashes Needed)
Age
Male
Female
Date of Birth
Occupation
Referred to Counseling by:
Are you receiving care from one of the other pastor's at the present time?
Yes
No
Personal History
Marital Status:
Single
Engaged
Married
Remarried
Separated
Divorced
Widowed
Date of Marriage:
Have you ever been separated from your present spouse?
Spouse's Name:
Spouse's Age:
Spouse's Occupatoin:
Children:
Religious History
Church Involement:
Medical History
Have you had any of the following physical problems? (please check all that apply)
Heart Problems
Bulimia
Menstural Irregularities
Liver Problems
Anorexia
Kidney Problems
Visual Problems
Hallucinations
Head Injury/Concussion
Sensory Distortion
Change in Sexual Drive
Stroke
Weakness
Seizures
Fatique
Problems Walking
Brain Tumor
Heat/Cold Sensitivity
Unusual Hair Loss
Multiple Sclerosis
Rashes
Parkinson's Disease
Bowel/Bladder Problems
Memory Problems
Blackouts
Nausea/Vomiting
Episodic Disorientation
Amnesia
Weight Change
Tremors
Impotence
Personality Change
Thyroid Dysfunction
Physical Change
Deja Vu
Diabetes
Constant Hunger
CHanges in Consciousness
Hypoclycemia
Food Cravings
Lung Problems
Fever
Headaches
Allergies
Pneumonia
Dizziness
Cancer
Speech Problems
Stiff Neck
High Blood Pressure
Incoordination
How many hours of sleep do you average each night? Have there been any recent changes? Is this sleep restful?
Have you or others noticed any changes in your thinking and memory, or work habits?
State in your own words the nature of the main challenge(s) that brings you for counseling:
When did your problems begin? (please specify a date if possible)
Please describe any significant events occuring at that time.
What have you done to try to resolve your problem(s)?
Is there any other information I should know?