Please enable JavaScript in your browser to complete this form.Contact Information - Step 1 of 12If the form below looks strange, please turn your phone so your screen is wide. 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? *EnglishSpanishWhat's the client's gender? *MaleFemaleWhat is your address? *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your date of birth? *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Emergency Contact *FirstLastEmergency Contact Phone *NextMarital Status *SingleEngagedMarriedSeparatedDivorcedWidowedWhat was your spouse's name? *FirstLastSpouse's Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Divorce *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Spouse's Passing *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Anniversary DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse phone numberSpouse emailNextDo you have children? *YesNoHow many children do you have?Child One: NameFirstLastChild One: Date of birthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Two: NameFirstLastChild Two: Date of birthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Three: NameFirstLastChild Three: Date of birthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child Four: NameFirstLastChild Four: Date of birthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920More Children (please include First, Last and Date of Birth)NextHave you or your family ever received counseling for any reason? *YesNoWhen?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was it for? *Why are you currently seeking counseling? *How long have you been experiencing this difficulty?DaysWeeksMonthsYearsAre you currently working with any other counselor or psychiatrist? *YesNoFor what reason and how long? *Counselor NameFirstLastAgency NameHave you experienced any loss in the past? *Death of spouseDeath of childDeath of fatherDeath of motherDeath of sisterDeath of brotherDeath of grandmotherDeath of grandfatherDeath of aunt or uncleSuicideMiscarriageAbortionAdoptionInfertilityBankruptcyHomelessnessJob lossDivorceOtherPlease explainCheck any concerns or issues you have now or in the past *Physical AbuseEmotional AbuseVerbal AbuseSexual AbuseAbortion and Abortion RelatedAlcohol AbuseAcademic IssuesAddictionAnger / RageAnxietyAttention Deficit Hyperactivity DisorderBinge EatingCareerChild LossCo-dependencyCommunicationCutting or self-harmDepressionDrugsPrescription drugsExcessive dieting or exercisePurgingFearGriefGender identityLonelinessMood SwingsNegative or troubling feelings about church or GodParent-Child CommunicationPeer PressurePornographyProcrastinationSelf-hatredStressSuicidal thoughtsSuicidal attemptSuicidal threatShoppingWorking too muchMorbidly ObeseOverwhelming DebtCurrent Financial ConcernsNextBriefly 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 ...) *NextReligious Faith *Christianity (Protestant)Christianity (Catholicism)IslamHinduismAgnosticismBuddhismAtheismSikhismSeventh-Day AdventistsLatter Day SaintJudaismProtestant DenominationBaptistNondenominationalMethodistPentecostalLutheranPresbyterianRestorationistEpiscopalian / AnglicanCongegationalistAdventistAnabaptistOther EvangelicalOther ReformedPietistQuakerUnsurePresent church affiliation or name of church you attend *Have you accepted Jesus as your Lord and Savior? *YesNo UnsurePlease 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?DailySeveral times per weekOnce per weekOnce per monthNeverDo you have a regular time to pray?YesNoHave you had any unusual "religious experiences"?YesNoPlease tell us about that... NextPhysician *FirstLastCityDate last seen.Reason for last appointment *Ongoing medical concerns *AllergiesMedications *NextLegal Issues *NoYes, previously or currentlyPlease explain. Charges *Serving Probation?YesNoCourt district?NextEducation Level *No High SchoolSome High SchoolHigh SchoolSome Higher EdAssociates DegreeBachelors DegreeMasters DegreeDoctoral DegreeHigher Ed - School NameGraduation DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are / Were you a service member? *Yes, currentlyYes, previouslyNoDate of enlistmentMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of dischargeMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of DischargeGeneral DischargeHonorable DischargeBad ConductDishonorable DischargeOther Than Honorable (OTH) DischargeWhat Branch?ArmyNavyAir ForceMarinesCost GuardSpecial ForcesOtherWhat Rank?If the form below looks strange, please turn your phone so your screen is wide. Relationships with TerribleBadNeutralGoodGreat PeersTerriblePeers TerribleBadPeers BadNeutralPeers NeutralGoodPeers GoodGreatPeers GreatSuperiorsTerribleSuperiors TerribleBadSuperiors BadNeutralSuperiors NeutralGoodSuperiors GoodGreatSuperiors GreatSubordinateTerribleSubordinate TerribleBadSubordinate BadNeutralSubordinate NeutralGoodSubordinate GoodGreatSubordinate Great ExplainNextAre you satisfied with your present occupation?YesNoWhat is your current occupation? *When did you start working with your current employer?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you satisfied with your present income?YesNoNextIf the form below looks strange, please turn your phone so your screen is wide. How is your? * TerribleBadNeutralGoodGreat AppetiteTerribleAppetite TerribleBadAppetite BadNeutralAppetite NeutralGoodAppetite GoodGreatAppetite GreatSleepTerribleSleep TerribleBadSleep BadNeutralSleep NeutralGoodSleep GoodGreatSleep GreatAbility to fall asleepTerribleAbility to fall asleep TerribleBadAbility to fall asleep BadNeutralAbility to fall asleep NeutralGoodAbility to fall asleep GoodGreatAbility to fall asleep GreatExerciseTerribleExercise TerribleBadExercise BadNeutralExercise NeutralGoodExercise GoodGreatExercise GreatWeight ControlTerribleWeight Control TerribleBadWeight Control BadNeutralWeight Control NeutralGoodWeight Control GoodGreatWeight 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?NextIs 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 thatWE CHOOSE TO BE BIBLICAL COUNSELORS, NOT LICENSED PROFESSIONAL COUNSELORS AND DO NOT BILL INSURANCE COMPANIES. *I understand. SignatureClear SignatureEmailSubmit