My Account
My Properties
Sign Out
My Account
My Properties
Sign Out
Home
About Us
Who We Are
Testimonials
Bible Study
Classes/Events
Blog
Counseling Intake Form
Coaching Intake Form
Invite us to speak
Pricing
Social
Connect
Gallery
Contact
More
Home
About Us
Who We Are
Testimonials
Bible Study
Classes/Events
Blog
Counseling Intake Form
Coaching Intake Form
Invite us to speak
Pricing
Social
Connect
Gallery
Contact
My Account
My Properties
Sign Out
Your Shopping Cart
No Items
Continue Shopping
951-878-1028
facebook
twitter
instagram
Intake Form
×
×
Date
Name
First Name
Last Name
Date of Birth
Gender
×
Please provide the required field.
Select
Male
Female
Age
Occupation
Address
Address1
Address 2
City
State
Zip
Home Phone
Area Code
Phone First 3
Phone Last 4
Work Phone
Area Code
Phone First 3
Phone Last 4
Cell Phone
Area Code
Phone First 3
Phone Last 4
Can we leave a message?
×
Please provide the required field.
Yes
No
Email
Employed At
# Emergency Contact Information
×
Please provide the required field.
Name
First Name
Last Name
Relationship
Phone Number
Area Code
Phone First 3
Phone Last 4
2) Relationship Status
×
Please provide the required field.
Current Relationship Status
×
Please provide the required field.
Married
Separated
Divorced
Single
How long have you been together?
How long have you been married?
How long have you known each other?
Prior to this marriage, how many times have you been engaged?
Have you ever been married before?
×
Please provide the required field.
Yes
No
How many times?
What are your current living arrangements?
×
Please provide the required field.
Own home
Renting
Living with someone else
3) Current Household Family
×
Please provide the required field.
Do you have children?
×
Please provide the required field.
Yes
No
If yes, please provide information below
×
Please provide the required field.
Name
First Name
Last Name
Age
Lives at
Choose One
×
Please provide the required field.
Biological
Adopted
Step-child
Name
First Name
Last Name
Age
Lives at
Choose One
Choose One
×
Please provide the required field.
Biological
Adopted
Step-child
4) Family-of-Origin
×
Please provide the required field.
Mother's Age
If deceased, how old were you when she died?
Father's Age
If deceased, how old were you when she died?
Number of Brothers
Their Ages
Number of Sisters
Their Ages
Briefly describe your relationship with your father
Briefly describe your relationship with your mother
Briefly describe your relationship with your siblings
5) Educational and Spiritual Background
×
Please provide the required field.
Select a Choice
×
Please provide the required field.
GED
HS Diploma
Associate's/Technical Degree
Bachelor's Degree
Post-Graduate Degree
Other
If degree applies please specify major
Were you affiliated with any church/religion growing up?
×
Please provide the required field.
Yes
No
What church/religion?
Are you currently affiliated with any church/religion?
×
Please provide the required field.
Yes
No
What church/religion?
Describe your religious upbringing
Describe your current relationship with God
What differences/similarities have you discussed concerning religion/spirituality?
6) Medical History
×
Please provide the required field.
Do you have any significant health/medical issues?
×
Please provide the required field.
Select
Yes
No
If yes, what is/are the health issue(s) and are you limited in any way?
Have you ever had any trauma to the head, unconsciousness, or seizures?
×
Please provide the required field.
Select
Yes
No
If yes, explain
Have you ever been hospitalized for any mental health reasons?
×
Please provide the required field.
Select
Yes
No
If yes, please explain when, where, for what reason, and what your presenting problem/diagnosis was
Are you taking psychotropic medications?
×
Please provide the required field.
Select
Yes
No
If yes, please list the medication, condition, dosage, dates of usage, side effects, and physician:
Do you currently use alcohol or drugs?
×
Please provide the required field.
Select
Yes
No
Describe the use of drugs and alcohol (type, amount, frequency)
When did you start using drugs or alcohol?
What has your past use of alcohol been like?
7) Counseling History
×
Please provide the required field.
Have you attended counseling previously?
×
Please provide the required field.
Select
Yes
No
If yes, please explain when (specify date), where and with whom, presenting issues at the time, and the diagnosis given
Have you ever attempted suicide?
×
Please provide the required field.
Select
Yes
No
If yes, when?
How many times?
Have you recently had thoughts of suicide?
×
Please provide the required field.
Select
Yes
No
If yes, how are what did you plan to do?
What were the circumstances at the time?
Has anyone close to you ever attempted suicide?
×
Please provide the required field.
Select
Yes
No
If yes, who, how, and when?
Have you ever been physically, emotionally, or sexually abused?
×
Please provide the required field.
Select
Yes
No
If yes, briefly explain (who, what, and when)
Do you have people you can turn to for support?
×
Please provide the required field.
Select
Yes
No
If yes, who?
Relationship to you
Briefly explain what concerns you would like to address during counseling
What do you hope to achieve or accomplish through counseling?
Please describe what you believe your spouse’s specific goals are for counseling
What concerns do you hope to resolve by the time you finish?
How did you hear about us?
Submit
×
×
First Name
Last Name
Email Address
Subject
Message
Submit
