Counselee Information Form
Please enter a valid phone number.
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?
Street Address Line 2
Marital Status (Single, Dating, Married, Separated, Divorced, Widowed)
Education (last year completed)
Referred here by
Rate your health:
Your approximate weight
Major changes in weight recently?
List all important present or past illnesses, injuries or handicaps
Date of last medical examination
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.
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
Have you ever had any psychotherapy or counseling before?
If yes, list counselor or therapist and dates:
What was the outcome?
Have you ever felt people were watching you?
Do people’s faces ever seem distorted?
Do you ever have difficulty distinguishing faces?
Do colors ever seem too bright or too dull?
Yes, too bright
Yes, too dull
Are you sometimes unable to judge distance?
Have you ever had hallucinations?
Are you afraid of being in a car?
Is your hearing exceptionally good?
Do you have problems sleeping?
Marriage and Family Information
Name of spouse
Education (in years)
Is your spouse willing to come for counseling?
Have you ever been separated?
If yes to above question, when?
Has either of you ever filed for divorce?
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.
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
List any other significant events after age 40 if applicable
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