counseling-form | FEMINC CHURCH

counseling form

Name*

Phone*( ) -

Best Method of Contact*

Phone

Address*

Date of Birth *

Gender*

Education (last year completed)

Rate Your Health*

Very Good

Good

Average

Declining

List all important present or past illnesses/injuries/disabilities:*

Are you presently taking medication?*

Yes

If applicable, please list drugs used for other than medicinal purposes:*

Date most recently used:*

Have you ever experienced severe emotional trauma?*

Yes

If so, explain:*

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

Yes

If so, explain:*

Have you recently suffered a loss from serious social, business or other reversals?*

Yes

If so, explain:*

Do you consider yourself a religious person?*

Yes

Do you believe in God?*

Yes

Do you question your salvation?*

Yes

Not

Not sure what you mean

Do you pray to God?*

Often

Sometimes

Rarely

Never

Do you have a regular daily devotion?*

Yes

Has there been any recent changes in your religious life?*

Yes

If so, explain:*

Have you ever had any psychotherapy or counseling before?*

Yes

If so, what was the outcome?*

Family Information

Spouse's Name

Spouse's Phone( ) -

Spouse's Age

Spouse's Religion

Is your spouse willing to receive counseling?

Yes

Not sure

Briefly answer the following questions:

Briefly describe yourself:*

Please describe the issue(s) that have caused you to seek counseling:*

What steps have you taken to address the problem(s):*

How do you feel we can help you with your situation:*

What are you expectations for receiving counseling:*

What, if anything, do you fear:*

Is there any other information we should know:*

What day would work best for your appointment? (Appointments available from 9:30am - 5pm)*

Monday

Wednesday

Friday

Please leave this field blank.