New Client Form

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Name *

First

Last

Birth Date (MM/DD/YYYY) *

Physical Address *

Phone Number *

Email *

attend married, Please

Best Contact Method *

• Text
• Email
• Phone

Marital Status (Choose One) *

• Married
• Divorced
• Single
• Widowed
• Separated
• Engaged

If married, how long have you been married? *

Emergency Contact (name, email, phone, relationship) *

Primary Reason for Seeking Counseling *

How long has this issue been ongoing? *

How difficult is this issue currently? *

• 1 (Not Difficult)
• 2
• 3
• 4
• 5 (Most Difficult)

Are you currently seeking additional help? *

• Medical
• Psychiatric
• Pastoral
• Other
• No, I do not

If yes, please describe below. *

Have you seen a professional counselor in the past? *

• Yes
• No

If yes, please describe how it went below. (duration, issue, outcome, etc) *

Do you currently have thoughts of suicide? *

• Yes
• No
• Not sure

Below is a list of concerns/conditions. Please check any that apply to you or your current situation *

• Depression
• Anxiety
• Suicide
• Isolation
• Fear
• Financial concerns
• Feeling numb
• Compulsions
• Physical problems
• Anger
• Worry/Stress
• Hopelessness
• Chronic conditions (of any kind)
• Difficulty making friends
• Racing thoughts
• Inability to focus
• Weight gain or loss
• Nightmares
• Problems with sleep
• Grief
• Any medical diagnosis
• Feeling manipulated
• Memory Issues or blackouts
• Work stress
• Hallucinations
• Feeling on edge
• Family stress or difficulty
• Infidelity
• Phobias
• Sexual issues or issues surrounding sexuality
• Physical pain
• Delusions
• Feeling unsafe
• Addiction (past or present)
• Learning Differences
• Marital Conflict
• Emotional Pain
• Paranoia
• Changes in appetite
• Difficulty with alcohol (past or present)
• Trauma or Abuse (past or present)
• Career concerns
• Obsessions
• None of the above
• Other

If other, please describe below:

If you attend church regularly, what is your "home" church?

Would you like prayer to a regular part of our counseling session?

• Yes
• No
• Maybe

Is there anything else you would like to share?

How did you hear about me? *

Submit

I will work to respond within two business days. Please note: This form and email are not monitored continuously and should not be used for emergencies. If you are in immediate danger, call 911. For emotional distress or a mental health crisis, call 988 or text 988. Veterans and service members may call 988 and press 1.