• Detailed Intake

    1948 N Plaza Dr. Rapid City, SD 57702

  • Please fill out this questionnaire as completely as possible. Your information will be kept confidential.

  • Today's Date*
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  • Basic Information

  • Birth date*
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  • Format: (000) 000-0000.

  • Educational & Vocational

  • Marital Data

  • Does your spouse know you are coming to receive counseling?*

  • Children

  • Rows

  • Family History

  • Rows
  • Rows

  • Health Survey

  • Date of last visit*
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  • Date of your last complete physical examination?*
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  • Do you have a history of drug use?*
  • Current use?*
  • Have you had a history of excessive use of alcohol?*
  • Do you presently?*
  • Have you been hospitalized for emotional problems?*
  • Have you taken medications for emotional problems?*
  • Have you experienced any recent significant weight loss or gain?*
  • Have you previously received counseling?*
  • If yes, was it helpful?*

  • Religious Background

  • Did you attend church as a young person?*
  • Was it a positive experience?*
  • Do you attend church now?*
  • Is it a positive experience?*
  • Have you made the great discovery of knowing Jesus Christ personally?*
  • Do you have a regular time of personal Bible Study?*

  • Personal History

  • Have you ever experienced child or spousal abuse?*
  • Have you ever experienced rape, incest or sexual molestation?*
  • Have you been involved in an out-of-wedlock pregnancy?*
  • Have you ever had an abortion?*
  • Have you ever attempted suicide?*
  • Has anyone close to you committed suicide?*
  • Rows
  • Are finances a recurring problem?*
  • Have you ever been involved in criminal activity?*
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  • Should be Empty: