Client Intake Form

Date(Required)

Referred by:

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Home)

Phone(Work)

Phone(Cell)

Employer(Required)

Position:(Required)

Gender(Required)

Male

Female

Age(Required)

Date of Birth

Relationship Status:(Required)

Single

Married

Separated

Divorced

Widowed

Religious Preference:(Required)

Church you belong to:

Name and telephone number of significant other (or person to contact in case of emergency).(Required)

Relationship to you(Required)

Phone(Required)

Children’s names and ages:

Child's Name

Age

I am seeking counseling and discipleship services for:(Required)

Individual

Couple

Family

Group

When?(Required)

Have you received counseling previously?(Required)

No

Yes

Name of your counselor:(Required)

State in your own words why you are seeking counseling at this time:(Required)

We do not give medical advice or recommendations about medications.
We are trained to use the Scriptures to address difficulties for those who seek help.

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