Your name:
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First Name
Last Name
If counselee is a minor, enter child's name:
First Name
Last Name
Email:
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Phone #:
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What is your preferred contact method?
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Address:
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Your occupation:
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Birth date:
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MM
DD
YYYY
Current age:
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Sex:
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Degrees / Other training or certifications:
Hobbies and interests:
How many siblings do you have?
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(List brothers, sisters, and birth order)
If you were raised by anyone other than your own parents, briefly explain:
Marital status:
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Single
Engaged
Married
Separated
Divorced
Remarried
Widowed
Other (explain below)
If "other," please explain:
Name of spouse:
Spouse's occupation:
Spouse's phone #:
Spouse's age:
Spouse's religion:
Spouse's education:
Does your spouse know you are coming for counseling?
Is your spouse willing to come to counseling?
Your age when married:
Your spouse's age when married:
Wedding date:
MM
DD
YYYY
How long did you know your spouse before marriage?
Length of steady dating with spouse:
Length of engagement:
Provide brief information about any previous marriages:
Information about children:
Name / Age / Sex / Education / Marital Status / Living? From a previous marriage?
Have you ever had a severe emotional upset?
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What was the outcome of this therapy or counseling?
Check off any of the following words which best describe you now:
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At any time have you:
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List fears you have:
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Approximately how many hours of sleep do you get each night?
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When do you go to sleep at night?
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When do you get up?
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Rate your health:
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Very Good
Good
Average
Declining
Other (describe in next section)
List all important present and past illnesses, injuries, or handicaps:
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Date of last medical examination:
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What was the report?
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Are you presently taking medication?
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List medications:
Have you used drugs for other than medical purposes?
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If yes, describe:
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?
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Denominational preference:
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May we contact your pastor for background information?
How many church services do you attend per month?
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Religious background of spouse:
Have you been baptized?
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Do you believe in God?
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Do you pray to God?
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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?
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Suppose you died today and God asked you “Why should I let you into my heaven?” What would you say?
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Are you saved?
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How much do you read the Bible?
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Does your family regularly read the Bible and pray together?
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Describe any recent changes in your religious life (if any):
What are the issues you are struggling with?
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What have you done about it?
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What do you want us to do? (What are your expectations in coming here?)
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What brings you here at this particular time?
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Is there any other information we should know?
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Consent Form Agreement
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Electronic Signature (Enter Name):
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