Client Intake - CV Biblical Counseling Center

Contact Information - Step 1 of 12

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What's the client's first and last name? (If a parent is filling this form out for a child, please list the child's name here and complete the form from their prospective. If more than one person is requesting counseling together, please fill out a form for each client.) *

How can we call you to schedule your first appointment? *

Where can we send emails? *

Can we...? (check all that apply)

Leave a Message on Voicemail?
Leave a Message with a Family Member?
Text You?
Contact your spouse?

Do you have a language preference? *

English
Spanish

What's the client's gender? *

Male
Female

What is your address? *

Address Line 1

Address Line 2

City

State

Zip Code

What is your date of birth? *

Emergency Contact *

First

Last

Emergency Contact Phone *

Marital Status *

What was your spouse's name? *

First

Last

Spouse's Date of Birth

Date of Divorce *

Date of Spouse's Passing *

Anniversary Date

Spouse phone number

Spouse email

Do you have children? *

How many children do you have?

Child One: Name

First

Last

Child One: Date of birth

Child Two: Name

First

Last

Child Two: Date of birth

Child Three: Name

First

Last

Child Three: Date of birth

Child Four: Name

First

Last

Child Four: Date of birth

More Children (please include First, Last and Date of Birth)

Have you or your family ever received counseling for any reason? *

When?

What was it for? *

Why are you currently seeking counseling? *

How long have you been experiencing this difficulty?

Are you currently working with any other counselor or psychiatrist? *

For what reason and how long? *

Counselor Name

First

Last

Agency Name

Have you experienced any loss in the past? *

Death of spouse
Death of child
Death of father
Death of mother
Death of sister
Death of brother
Death of grandmother
Death of grandfather
Death of aunt or uncle
Suicide
Miscarriage
Abortion
Adoption
Infertility
Bankruptcy
Homelessness
Job loss
Divorce
Other

Please explain

Check any concerns or issues you have now or in the past *

Physical Abuse
Emotional Abuse
Verbal Abuse
Sexual Abuse
Abortion and Abortion Related
Alcohol Abuse
Academic Issues
Addiction
Anger / Rage
Anxiety
Attention Deficit Hyperactivity Disorder
Binge Eating
Career
Child Loss
Co-dependency
Communication
Cutting or self-harm
Depression
Drugs
Prescription drugs
Excessive dieting or exercise
Purging
Fear
Grief
Gender identity
Loneliness
Mood Swings
Negative or troubling feelings about church or God
Parent-Child Communication
Peer Pressure
Pornography
Procrastination
Self-hatred
Stress
Suicidal thoughts
Suicidal attempt
Suicidal threat
Shopping
Working too much
Morbidly Obese
Overwhelming Debt
Current Financial Concerns

Briefly describe yourself *

Briefly describe your spouse

Identify and describe your primary female caregiver as you remember during your life at home. List some of her characteristics as a person. *

Identify and describe your primary male caregiver as you remember during your life at home. List some of his characteristics as a person. *

How did your parents or caregivers get along with each other while you were in the home. *

Describe any significant problems between you and your brothers and sisters. *

List any relatives with a history of emotional and mental disorder or suicide (include diagnosis and treatment, if known). *

List relatives with a history of alcoholism or excessive alcohol or drug use. *

List any significant past trauma experiences by you or those close to you (ie death, divorce, sickness, crime, etc ...) *

Religious Faith *

Christianity (Protestant)
Christianity (Catholicism)
Islam
Hinduism
Agnosticism
Buddhism
Atheism
Sikhism
Seventh-Day Adventists
Latter Day Saint
Judaism

Protestant Denomination

Present church affiliation or name of church you attend *

Have you accepted Jesus as your Lord and Savior? *

Yes
No
Unsure

Please tell us about that...

Have your religious experiences and training helped or hurt your ability to deal with your struggles?

How often do you read your bible?

Daily
Several times per week
Once per week
Once per month
Never

Do you have a regular time to pray?

Have you had any unusual "religious experiences"?

Please tell us about that...

Physician *

First

Last

City

Date last seen.

Reason for last appointment *

Ongoing medical concerns *

Allergies

Medications *

Legal Issues *

No
Yes, previously or currently

Please explain.

Charges *

Serving Probation?

Court district?

Education Level *

Higher Ed - School Name

Graduation Date

Are / Were you a service member? *

Yes, currently
Yes, previously
No

Date of enlistment

Date of discharge

Type of Discharge

General Discharge
Honorable Discharge
Bad Conduct
Dishonorable Discharge
Other Than Honorable (OTH) Discharge

What Branch?

Army
Navy
Air Force
Marines
Cost Guard
Special Forces
Other

What Rank?

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Relationships with

	Terrible	Bad	Neutral	Good	Great
Peers	TerriblePeers Terrible	BadPeers Bad	NeutralPeers Neutral	GoodPeers Good	GreatPeers Great
Superiors	TerribleSuperiors Terrible	BadSuperiors Bad	NeutralSuperiors Neutral	GoodSuperiors Good	GreatSuperiors Great
Subordinate	TerribleSubordinate Terrible	BadSubordinate Bad	NeutralSubordinate Neutral	GoodSubordinate Good	GreatSubordinate Great

Explain

Are you satisfied with your present occupation?

What is your current occupation? *

When did you start working with your current employer?

Are you satisfied with your present income?

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How is your? *

	Terrible	Bad	Neutral	Good	Great
Appetite	TerribleAppetite Terrible	BadAppetite Bad	NeutralAppetite Neutral	GoodAppetite Good	GreatAppetite Great
Sleep	TerribleSleep Terrible	BadSleep Bad	NeutralSleep Neutral	GoodSleep Good	GreatSleep Great
Ability to fall asleep	TerribleAbility to fall asleep Terrible	BadAbility to fall asleep Bad	NeutralAbility to fall asleep Neutral	GoodAbility to fall asleep Good	GreatAbility to fall asleep Great
Exercise	TerribleExercise Terrible	BadExercise Bad	NeutralExercise Neutral	GoodExercise Good	GreatExercise Great
Weight Control	TerribleWeight Control Terrible	BadWeight Control Bad	NeutralWeight Control Neutral	GoodWeight Control Good	GreatWeight Control Great

Have there been any changes in your appetite, sleep or exercise in the last six months? Please explain.

What are you exercise habits?

Is there anything else you want your counselor to know?

How did you hear about the CV Biblical Counseling Center? *

Thank you for filling out our intake form, please check this box and sign below acknowledging you are aware that

WE CHOOSE TO BE BIBLICAL COUNSELORS, NOT LICENSED PROFESSIONAL COUNSELORS AND DO NOT BILL INSURANCE COMPANIES. *

I understand.

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