Counseling Ministry Intake Form

• Name * First Last
• Birthdate *
• Gender

  Male Female
• How would you best describe your race and/or ethnicity? *
• Address *
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code United StatesUnited KingdomAustraliaCanadaFranceNew ZealandIndiaBrazil----AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsCuracaoNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country
• Cell Phone Number
• Home Phone Number
• Work Phone Number
• Please provide consent to receive messages via the following (check ALL that apply)
• Voicemail Text Email
• Email *
• Emergency Contact Name:
• Emergency Contact Phone:
• Relationship
• Employment:

  Self Other
• Please describe
• How did you find the Counseling Ministry or who referred you?
• Status:

    Single Married Separated Divorced Remarried Widow(er) Living with
• Years Married
• Years Divorced
• Years Together
• Partner's Name
• Partner's Date of Birth
• Name/ages of children
• Level of Education

  Some High School High School Graduate or Equivalent Trade or Vocational Degree Some College Associate Degree Bachelor's Degree Graduate or Professional Degree Prefer Not to Answer
• What church do you attend? SBC: Shea Cactus North Ridge Fountain Hills
• Other
•  
• How often?
• On a scale of 1-10 how sure are you that if you died tonight that you would go to heaven? (1 being not so sure-10 being absolutely positive)
• Describe briefly your relationship with God
• Describe any involvement in your life in cults or the occult
• Describe your religious upbringing
• Describe any specific religious/spiritual values/beliefs that you now hold
• What hobbies, if any, do you have?
• What do you do for recreation, physical activity?
• Do you smoke? If so, how much?
• Please list any past or present alcohol or drug use or amounts
• Are you concerned about your current drug or alcohol use and amounts?

    Yes No
• How would you describe your current physical health?

  Excellent Good Fair Poor
• Are you currently experiencing any physical problems? (e.g. headaches, body aches, stomach problems)

  yes no
• If yes, please explain
• Date of last physical examination
• Medication(s)-Prescription or Over the Counter. Please include dosage and how long have been taking
• Physician's Name and Phone Number
• Previous hospitalizations for medical reasons. Please list date and reason
• Previous hospitalizations for mental health treatment. Please list approximate dates and duration
• If yes, please explain including name of hospital, doctor, and phone number
• Have you ever had any previous counseling experience?

  yes no
• Describe reason for counseling
• Approximate dates and duration
• Counselor's name and address
• What were the results of your counseling experience?
• Have you ever had serious thoughts about suicide? *

  Yes No
  How long ago?*
• Have you ever attempted suicide? *

  Yes No
  How long ago?*
• What concerns have led you to pursue counseling today?
• Where are your concerns causing the most problems for you? Check all that apply

  Home Work Relationship God
• When did the problem begin? How long?
• Have any concerns about you been identified by others?
• Please indicate which of the following areas are currently problems for you. Check all that apply

  Excessive anxiety or worry Feeling lonely Angry feelings Concerns about finances Feeling "numb" or cut off from emotions Angry outbursts Excessive fear of specific places/objects Difficulty making friends Feeling as if you'd be better off dead Feeling manipulated or controlled by others Difficulty making decisions Loss of interest in sexual relationships Feeling sexually attracted to those of your own sex Concerns about physical health Blackouts or temporary loss of memory Insomnia (no sleep) or Hypersomnia (sleep all the time) Loss of appetite/increased appetite Lacking self-confidence Issue with food and/or weight Abuse of alcohol and/or non-prescription drugs Delusions Feeling distant from God Hallucinations Inability to concentrate while at school/work Crying spells Nightmares Loss of interest in usual activities/lack of motivation Obsessions or compulsions with specific activities Inability to control thoughts Feeling trapped in rooms/buildings Hearing voices Feeling that people are "out to get you" or that you're being watched
• What would you like to accomplish or gain from your sessions with the Counseling Ministry?
• What action have you taken to deal with the above situation? ie: small group, support group, etc
• Describe any strengths or weaknesses that you have that would either help or hinder the problem
• Do you have any resources that might be helpful in this situation? ie friends, relatives, etc
• What additional information would you like to share?
• Do Not Fill This Out