ALL INFORMATION IS TREATED WITH STRICTEST CONFIDENCE
P L E A S E P R I N T L E G I B L Y
Personal Information
Please state briefly the presenting difficulty____________________________________________________________
______________________________________________________________________________________________
Are you currently experiencing any suicidal thoughts? Yes ____ No ___
Level of Distress: Please indicate your level of distress _______________________________________
by placing an ‘X’ on the scale 1 2 3 4 5
LOW MODERATE EXTREME
Previous counseling: When? _______________________________ Where? _________________________________
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Name of Family Member(s)
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Date of Birth
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Age
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Relationship to Patient
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Living in the home (Y/N)
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Nearest relative not living with you ______________________________________ Phone ( ) ________________
Nearest friend not living with you _______________________________________ Phone ( ) ________________
Church Membership_______________________________________ Pastor _________________________________
Who referred you to Christian Therapy Services or this Therapist?__________________________________________
Medical Information
Physician _________________________________________________________ Phone ( ) _______________
Address __________________________________________________________ FAX ( ) _______________
Date of last medical exam or physical _____________________________________________________________
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Current Medication(s)
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Dosage
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Date Started
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Treatment for
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Occupation Information
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Employer
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Address
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Phone
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Self
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Spouse
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Present Issues and Goals
Why have you decided to come to counseling now? ______________________________________________
________________________________________________________________________________________
What are your personal goals for counseling? ___________________________________________________
________________________________________________________________________________________
What positive things have happened since you made your appointment? ___________________________
________________________________________________________________________________________
If a miracle were to occur overnight, regarding your reason for coming into counseling, what would be different and how would you know it?
________________________________________________________________________________________
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Religious Background
What words would you use to describe yourself: _________________________________________________
________________________________________________________________________________________
If God were to describe you, what would He say? ________________________________________________
________________________________________________________________________________________
Briefly describe the religious environment of your home as you were growing up: _______________________
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Relationship/Marriage Issues (Couples ONLY)
How long have you been a couple? ___________ How long have you been married? ____________
What is the event or series of events that brought you to see a Therapist today? ________________________
________________________________________________________________________________________
What are a couple of positive things that have happened, as a couple since you have made your appointment?
________________________________________________________________________________________
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What are you willing to do to help your relationship improve? _______________________________________
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