Counseling Intake Form - Providence Church printable pdf download

Providence Church

Counseling Intake Form

Today’s Date: _______________________

Name: __________________________________ Date of Birth: ____________________ Age: ___________

Address: _____________________________City _________________State _________Zip_________________

Primary Phone: (_____)_____________ Cell____ Home ___ Work ____

Other phone: (______)______________ Cell____ Home ___ Work ____

Is it alright to leave a message? _______

Email (only if you would like to use this as a form of communication): ____________________________________

Occupation ___________________________________ Place of Employment_______________________________

Marital Status:

( ) Single

( ) Married year _______

( ) Divorced year _______

( ) Remarried year _______

( ) Engaged

( )Widowed year _____

Spouse’s Name: ________________________________________________________________________________

Spouse’s Occupation: ______________________ Place of Employment: __________________________________

Children:

Name

Gender

Age

Relationship

Living in Home

Grade/occupation

_________________________________________________________________________________________

Briefly describe/explain the presenting problem(s):

____________________________________________________________________________________________________

________________________________________________________________________________________________

Briefly explain what has been tried to resolve the problem(s):

____________________________________________________________________________________________________

________________________________________________________________________________________________

Please list any counseling/therapy you have sought, past or present:

____________________________________________________________________________________________________

_________________________________________________________________________________________________

________________________________________________________________________________________________

Please list any medications you are currently taking:

____________________________________________________________________________________________________

________________________________________________________________________________________________

Counseling Intake Form - Providence Church