Confidential Intake Form

First Name Last Name

example@example.com

Area Code Phone Number

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

First Name Last Name

Area Code Phone Number

Caucasian African American Asian Hispanic Other__________

Social Media Word of Mouth Church Radio Internet (not including social media)

Married Single Divorced Separated Widowed

Yes No

(Yes or No)

If so, who?

Spouse Children Parent Pastor Friend(s) Doctor

For your first pregnancy (or the one you were involved in):
How old were you?blanks
What was your marital status?
Did you feel pressured into the abortion and if so, by whom? blank
Were you in favor of the abortion?     yes   no
Do you know the gender of the baby?   yes       no
Type of abortion if known:
What was the outcome of that relationship?

For your second pregnancy (or the one you were involved in):
How old were you?blanks
What was your marital status?
Did you feel pressured into the abortion and if so, by whom? blank
Were you in favor of the abortion?     yes   no
Do you know the gender of the baby?   yes       no
Type of abortion if known:
What was the outcome of that relationship?

For your third pregnancy (or the one you were involved in):
How old were you?blanks
What was your marital status?
Did you feel pressured into the abortion and if so, by whom? blank
Were you in favor of the abortion?     yes   no
Do you know the gender of the baby?   yes       no
Type of abortion if known:
What was the outcome of that relationship?

For your fourth pregnancy (or the one you were involved in):
How old were you?blanks
What was your marital status?
Did you feel pressured into the abortion and if so, by whom? blank
Were you in favor of the abortion?     yes   no
Do you know the gender of the baby?   yes       no
Type of abortion if known:
What was the outcome of that relationship?

For your fifth pregnancy (or the one you were involved in):
How old were you?blanks
What was your marital status?
Did you feel pressured into the abortion and if so, by whom? blank
Were you in favor of the abortion?     yes   no
Do you know the gender of the baby?   yes       no
Type of abortion if known:
What was the outcome of that relationship?

Yes No Yes, and I would like my counselor to contact you so you can share more about the retreat with him/her. No, I would not like my counselor to contact you (we recommend that you tell your counselor that you are attending this retreat.

Clear

Are you currently affiliated with any church?blanks if so, what is the name of the church and denomination?blank Do you believe in the trinity of God? (God the Father, God the Son, God the Holy Spirit?
Do you consider yourself a Christian?      If yes, how long have you been a Christian?      If no, what is your religious affiliation, if any?

Born again Saved Have a personal relationship with Jesus Christ Gradual revelation or conversion to Christ Spirit Filled

Clear

Confidential Intake Form

Pregnancy History