New Client Intake Form Please fill out this form in preparation for our first session together. Please let us know if you have any questions. We look forward to seeing you soon. Client Intake Form Counseling Intake Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Relationship Status Single Married Separated Divorced Widowed If married, how long have you been married? Children If you have children, please list their names and ages. Church Status Are you currently attending church? If so, which one and for how long? If not, what are the circumstances? Emergency Contact (Name & Phone Number) PLEASE ANSWER THE FOLLOWING QUESTIONS AS HONESTLY AS POSSIBLE. Briefly describe why you have chosen to seek counseling. What do you hope to achieve throughout the counseling process? Briefly list two or three goals. Do you consider yourself a believer in Jesus Christ? If yes, how long? If not, is there a specific area of doubt? Have you had counseling before? If so, what did you like or dislike? Please check all that apply to you at this time. I feel depressed I feel hopeless I feel angry I feel anxious I feel fearful I struggle with anger I feel sad I struggle with bitterness I abuse alcohol I use prescription drugs I view pornography I strongly fear rejection I have suffered recent loss I think of suicide I feel worthless I use illegal drugs I abuse prescription drugs I struggle as a parent I struggle sexually I am having marital problems I struggle with my in-laws My spouse is a poor communicator My spouse has committed adultery I am a poor communicator I have committed adultery I have been sexually abused I have been verbally abused I have been physically abusive I have been sexually abusive I don't know much about the Bible What did I miss? Is there any other information about you or any struggles you are facing that would be helpful for me to know before we get started? Thank you!
