Center For Individual & Family Therapy A Christian Counseling Center Family Forms Page 5
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6FAMILY PERSONAL DATA
This is a confidential record of your personal history. Information contained in it will not be released to anyone
unless authorized by you or required by the law as explained in our consent to treatment.
Date
Referred By
Client: Family Name
Names
Date of
Age
Gender
Marital Status
Occupation
Highest Grade
Birth
(married, single,
Completed
divorced, other)
Address
City
Zip Code
Home Phone(_____)
Cell Phone(____)
Minor’s Cell Phone(_____)
Person to notify in case of emergency
Phone Number
Ethinicity
Would the family like spirituality/religious issues to be a part of your therapy? Y
/ N
/
Don’t Know
NOTE: It is important for the family and therapist to determine together what part spiritual/religious issues
will or will not take in therapy.
Client Signature
What changes would you like to see in your family as a result of therapy?
How have you attempted to deal with this problem thus far?
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