Counseling Intake Form
(Each person desiring counseling needs to fill out separate form.)
Select a date
(Street, City, State, Zip)
(No Dashes Needed)
Date of Birth
Referred to Counseling by:
Are you seeing another counselor at the present time?
Relation to You:
Which might have applied during your childhood and/or adolescence:
Date of Marriage:
Have you ever been separated from your present spouse?
Spouse's Previous Marriages:
What jobs have you held in the past?
Does your present work satisfy you?
Are you a Member?
Permission to Contact Pastor:
Church Phone Number:
Do you believe in God?
Do you consider yourself "saved"?
Not sure what you mean.
If you were to die and stand before God and He asked you why He should permit you to enter Heaven, how might you respond?
Have you had any of the following physical problems? (please check all that apply)
Change in Sexual Drive
Unusual Hair Loss
CHanges in Consciousness
High Blood Pressure
Date of last Physical Exam:
List all prescription and over the counter medications:
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?
As you see yourself, what kind of person are you?
State in your own words the nature of the main problem(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)?
What would you like us to do for you? What kind of help do you want from us?
Is there any other information we should know?