Name
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
*
Date of Birth
*
Place of Birth
*
Name/Age of Children
*
Who are the important people in your life?
*
Education Level
*
Employer
*
If you occupy a ministry or leadership role at a church, do they know that you are seeking help?
*
If yes, for how long and what role?
*
Present interests, hobbies and activities
*
How is most of your free time occupied?
*
Share in your own words the nature and history of your chief complaint
*
What are your goals? What is the 'win' you are looking for?
*
What has kept you from experiencing this already?
*
Father's Name
*
Age
*
Health Status
*
If deceased, age and cause of death
*
Your age at the time of father's death
*
Description of your father's personality
*
Mother's Name
*
Age
*
Health Status
*
If deceased, age and cause of death
*
Your age at time of mother's death
*
Description of your mother's personality
*
How would you describe your own personality?
*
Brothers/Sisters
*
(Names, sex, age and something about each)
Have you ever been under counseling or in therapy before?
*
If yes, when?
*
Have you ever been hospitalized for an emotional problem?
*
If yes, when, where and for how long?
*
Have you ever made a suicide attempt?
*
Have any close relatives been treated for psychiatric problems?
*
If yes, please specify
*
Do you have an significant or choleric medical conditions or pain?
*
If yes, please specify
*
Are you currently using any prescription drugs or others?
*
If yes, please specify
*
Do you consume alcohol?
*
If yes, how much, how often?
*
Is your diet unusual in any way?
*
If so, how?
*
Symptoms
(Check any of the following symptoms that apply to you at this time.)
Other Symptoms?
Thoughts
(Check any that apply)
Other Thoughts?
Reflections on why you checked these?
Feelings
(Check any that apply)
Reflections on why you checked theses?
Behaviors
(Check any that apply)
Do you exercise regularly
*
Please describe any current/past activity levels and any concerns
*
Name of coach or counselor that you are meeting with
*
