Counselee Information Form
Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date
/
Month
/
Day
Year
Date
Please answer the following questions:
1. What is the main problem as you see it? What brings you here?
2. What have you done about it?
3. What can we do? What are your expectations in coming here?
4. As you see yourself, what kind of person are you? Describe yourself.
5. Is there any other information that we should know?
Identification Data
Address
Address
Street Address Line 2
City
State
Zip
Occupation
Sex
Birth Date
/
Month
/
Day
Year
Date
Age
Marital Status (Single, Dating, Married, Separated, Divorced, Widowed)
Education (last year completed)
Referred here by
Health Information
Rate your health:
Very Good
Good
Average
Declining
Your approximate weight
Major changes in weight recently?
Gained weight
Lost weight
List all important present or past illnesses, injuries or handicaps
Date of last medical examination
/
Month
/
Day
Year
Date
Are you currently taking any medication? If so, what?
Have you used drugs for anything other than medical purposes? If so, what?
Have you ever had a severe emotional upset? If so, explain.
Have you ever been arrested?
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? (Yes or no)
Have you recently lost anyone close to you? If yes, explain.
Religious Background
Denominational preference
Are you a member of a church? Which one?
How often do you attend church each month?
Church attended in childhood
Religious background of spouse (if married)
Do you consider yourself a religious person?
Do you believe in God?
Do you pray to God?
Are you saved?
How much do you read the Bible?
Do you have regular family devotionals? (If applicable)
Explain recent changes in your religious life. if any
Personality Information
Have you ever had any psychotherapy or counseling before?
Yes
No
If yes, list counselor or therapist and dates:
What was the outcome?
Have you ever felt people were watching you?
Yes
No
Do people’s faces ever seem distorted?
Yes
No
Do you ever have difficulty distinguishing faces?
Yes
No
Do colors ever seem too bright or too dull?
Yes, too bright
Yes, too dull
No
Are you sometimes unable to judge distance?
Yes
No
Have you ever had hallucinations?
Yes
No
Are you afraid of being in a car?
Yes
No
Is your hearing exceptionally good?
Yes
No
Do you have problems sleeping?
Yes
No
Marriage and Family Information
Name of spouse
Occupation
Education (in years)
Religion
Is your spouse willing to come for counseling?
Yes
No
Have you ever been separated?
Yes
No
If yes to above question, when?
Has either of you ever filed for divorce?
Yes
No
If yes to above question, when?
How long have you been married?
How long did you know your spouse before marriage?
How long did you date your spouse before engagement?
Length of engagement
Give brief information about any previous marriages
Please list any children, their names, age, sex, and any other pertinent information about them:
If you were raised by anyone other than your own parents, briefly explain:
If you have an siblings, please list their names and ages here.
Life Story
Tell me what you can remember from your earliest memories. I am only looking for a synopsis, so don’t include every detail. However, I do want to get to know you and what things have influenced, shaped, and grown you or what circumstances have been difficult for you- in other words, tells me the good AND the bad.Please try to include your thoughts about your faith as much as possible throughout.For example:0-12 (tell us about your family of origin, what shaped your life, how you responded)• Raised by single mom• Traumatic history of abuse• Loss of dear family member• Fond memories of vacation with family• Grew up in a home that was religious by name only• Knew God but didn’t live my faith
Ages 0-12
Ages 13-18
Ages 19-22
Ages 23-29
Ages 30-40
List any other significant events after age 40 if applicable
Submit
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