WAFIF Counselling-Personal Data Form (Adult)

WAFIF Counselling /Coaching Personal Data Form

Please fill in the form below
Name*

First NameMiddle NameLast Name
E-mail*
Gender*
Date of Birth*

MonthDayYear
Contact Number:*

Area CodePhone Number
Marital Status
Address:*

Street Address

Street Address Line 2

CityPArish/State / Province

Postal / Zip CodeCountry
Occupation
Work Address & Phone Number:
Spouse's Name /Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Spouse's Occupation
Spouse's Age
Years of Marriage
Have you ever been separated from current spouse?

YesNoOther
If yes, please state duration and cause.
Do you have any children?

YesNoOther
If yes, please state ages and gender.
Denominational Preference
Church you presently attend. (Name Address, Contact Number)
Name of Pastor

First NameLast Name
Permission to consult with your pastor:

YesNo
Do you believe in God?

YesNo
Do you consider yourself to be saved?

YesNoNot sure what that means
Write 5 words you would use to describe yourself.*
What do you do for fun?*
State in your own words the nature of your main problem(s) (Your reason(s) for coming here.*
Please check the items that you believe are affecting you. If you are signing this form for your child /ward tick those that apply to him/her.

Alcohol or drug problemsAnxiety, nervousness, fearsEating or Appetite problemsProcrastinationRelationship/marital concernsShynessSocial conflictsStressSelf-controlWork or career concernsSpiritual Problems/My Walk with ChristAbnormal BehaviourAnger or hostile feelingsSadness or DepressionFamily issuesPhysical DistressSexual ConcernsTraumaSuicidal thoughts or behavioursProblems sleepingLow-self esteem or lack of confidenceGriefDisobedienceLearning ChallengesFeeling Rejected
What can we do? (What are yourexpectations in coming here?)
Do you have problem submitting to Authority (Parents, Government official, Pastor etc)

YesNo
Type a question
If yes, please elaborate.
Have you ever thought of doing any harm to yourself or others?*

YesNo
If yes, please state when and elaborate.
Signature of Client*
Date of Submission*

MonthDayYear
Date
Should be Empty:

WAFIF Counselling /Coaching Personal Data Form