Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Sex *

Male

Female

Primary Phone *

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Rate Your Overall Health *

Very Good

Good

Average

Declining

Other

Date of Last Medical Examination *

MM

DD

YYYY

Address of Primary Care Physician *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently taking any medication? *

Yes

No

Have you ever used drugs for other than medical purposes? *

Yes

No

Have you ever been arrested? *

Yes

No

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports if needed? *

Yes

No

Have you recently suffered the loss of someone who was close to you? *

Yes

No

If so, when?

MM

DD

YYYY

How often do you get physical exercise?

Daily

Weekly

Rarely

Never

Marital Status *

Single

Dating

Engaged

Married

Separated

Divorced

Widowed

Spouse's Date of Birth

MM

DD

YYYY

Spouse's Phone (Primary)

(###)

###

####

Spouse's Phone (Work)

(###)

###

####

Spouse's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is you spouse willing to to come for counseling?

Yes

No

Uncertain

Have you ever been separated?

Yes

No

Have either of you ever filed for divorce?

Yes

No

Date of Marriage?

MM

DD

YYYY

Do you have any children? *

Yes

No

Child #1

First Name

Last Name

Date of Birth

MM

DD

YYYY

Sex

Male

Female

Is this child from a previous marriage or relationship?

Yes

No

Living?

Yes

No

Married?

Yes

No

Child #2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Is this child from a previous marriage or relationship?

Yes

No

Living?

Yes

No

Married?

Yes

No

Do you regularly attend church?

Yes

No

Are you a member of a church?

Yes

No

Do you attend a Small Group / Sunday School?

Yes

No

Do you consider yourself a religious person?

Yes

No

Uncertain

Do you believe in God?

Yes

No

Uncertain

Do you believe Satan exists?

Yes

No

Uncertain

Have you ever "dabbled" with the Occult (Seances, devil worship, witchcraft, etc)?

Yes

No

Uncertain

Do you pray to God?

Yes

No

Would you say that you are a Christian?

Yes

No

Uncertain / Still in the process of becoming a Christian

How often do you read the Bible?

Never

Occasionally

Often

Do you have regular devotions?

Yes

No

Not sure what you mean