New Client Form

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Name *

First

Last

Birth Date (MM/DD/YYYY) *

Physical Address *

Email *

Best Contact Method *

Marital Status (Choose One) *

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? *

Are you currently seeking additional help? *

If yes, please describe below. *

Have you seen a professional counselor in the past? *

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

Do you currently have thoughts of suicide? *

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

If other, please describe below:

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

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

below. currently situation

Is there anything else you would like to share?

How did you hear about me? *

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