Confidential Client Intake Form
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3CONFIDENTIAL CLIENT INTAKE FORM
Name:
Today’s Date:
Sex:
Male
Female
Date of Birth:
Age:
Address:
City:
State:
Zip:
Phones: (W)
(H)
(C)
Any number you do not want to be contacted at:
Email:
Check here if you want Christian counseling
Do you regularly attend a church, synagogue, or other religious institution?
Yes
No
If yes, which one?
RELATIONAL INFORMATION
Current marital status:
Single
Engaged
Married
Separated
Divorced
Widowed
If engaged, married, separated, divorced, or widowed, for how long?
Number of previous marriages for you:
For your spouse:
If married, spouse’s name:
Age:
Is your spouse supportive of you seeking counseling?
Yes
No
Unsure
Spouse doesn’t know
Please provide a brief description of your spouse (e.g., angry and controlling; outgoing and supportive):
What is your current occupation?
What is your level of satisfaction with your occupation?
Please list your children (including step, adopted, foster) below:
Name
Sex
Age or yr. of death
Relationship to you
Living with whom?
Who else lives with you?
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