Intake Form - Christian Heart Counseling

Client Name*

First Last

Parent/Guardian Name (If Applicable)

First Last

Address

Street Address Address Line 2 City State ZIP Code

E-Mail Address*

Phone (Home)

Phone (Cell)*

Okay to leave a message?

Yes
No

Subscribe to our newsletter?

Yes
No

Date of Birth*

How did you find us?

First name of Spouse (if applicable)

What brings you in today?

First goal of therapy

Second goal of therapy

Third goal of therapy

Previous counseling

Current employment and do you like it?

Education

Marriages/Relationships

Children

Siblings

Parents and Marital Status

Significant Life Events

Trauma

Current Living Situation

Financial Concerns

Hobbies/Interests

Medication One (Name Dose)

Medication Two (Name Dose)

Medication Three (Name Dose)

Ever have a head injury as child or adult?*

Yes
No

Have you ever felt you should cut down on your drinking or drug use?*

Yes
No

Have people annoyed you by criticizing your drinking or drug use?*

Yes
No

Have you ever felt bad or guilty about your drinking or drug use?*

Yes
No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?*

Yes
No

Have you had any issues with other substance besides alcohol?*

Yes
No

What role does religion/spirituality play in your life?

Any Current or past Thoughts of Suicide?*

Yes
No

General medical condition:*

Good
Fair
Poor

Family history of mental health issues?

Client Intake Form

(If couple, each does a separate intake form)

Office Locations

Quick Links

Business Office Hours

Insurance We Accept