(Highest Level Achieved/Major/Licensing)
Referred for counseling by:
Is He Living
Is She Living
If your parents divorced, how old were you?
Describe your parents marriage. Check all that apply.
Fighting, Anger, Threats
Yelling, Hurtful Words
Little of no showing of affection
Very little communication
How did you feel during childhood? Check all that apply.
Had lots of friends
Happy - Non-Christian Home
Unhappy - Non-Christian Home
Happy Christian Home
Unhappy Christian Home
Which parent were you closest to?
State of Residence
Jobs you have held in the past 5 years, dates of employment, and reasons for leaving.
Does your current work satisfy you? Please explain why or why not.
If you aren't single, list when your status changed.
If engaged, how long did you date?
If married, how long were you engaged?
How many times
Describe your current marriage. Check all that apply.
Fighting, anger, threats
Yelling, hurtful words
Little or no showing of affection
Very little ocmmunication
Please list any history of mental, emotional, psychological, or sexual suffering that would help us to understand you better.
Living at Home
If you have more children, list their details here.
Name of Church Currently Attending
Address of Church Currently Attending
Church Phone Number
Denomination/Affiliation/Church Growing Up
Current church attendance per month
Do you believe in God
Do you pray to God
How often do you pray
Has your praying changed recently
Are you saved
Please write your testimony of salvation
How often do you read the Bible
Which translation(s) do you prefer
Do you believe the entire Bible is true and without errors
Has your Bible reading changed recently
What physical problems have you had, or currently have? Check all that apply.
Nausea or vomiting
Change in sex drive
Recent weight changes
Unusual hair loss
List all the prescriptions and over-the-counter-medications you are currently taking. Please list dosage and frequency. (Over-the-counter medication examples: diet pills, laxatives, birth control pills, cold &allergy medications, etc.)
If you have ever used drugs for other than medical purposes, please explain
List all important present or past illnesses, injuries, handicaps, or anything else that is affecting your health. Please include past or present addictions.
Date of last medical exam
If female, list last OB/GYN exam
Have you ever had severe emotional upsets?
Have you had psychotherapy, psychological, or any other counseling?
Date(s) of counseling
Favorite verse/passage in the bible and why
Favorite song/group, religious or otherwise, and why
Do you have any hobbies, and if so what are they
If you have ever been arrested, list when, how many times, and the details of your arrest
State in your own words what the main problem(s) is/are from your point of view.
What have you done about it?
What are your expectations in coming here? How are you going to evaluate/measure success?
Please review and date this document before sending.
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