Client Consultation
Name
*
First Name
Last Name
D.O.B.
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
May I leave a general voicemail?
*
Yes
No
May I text an appointment reminder?
*
Yes
No
Marital Status
*
Single
Single in relationship
Engaged
Married
Separated
Divorced
Widowed
Name of spouse or significant other:
Will your spouse or significant other be attending counseling?
*
Yes
No
Children (names/ages):
Occupation:
*
Employer:
In the event of an emergency, I give ResoluteBC permission to contact:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you:
*
How did you hear about ResoluteBC?
*
Have you had previous counseling?
*
Yes
No
If yes, with whom? (name/city)
Have you ever been hospitalized for a psychiatric condition?
*
Yes
No
If yes, please describe:
Diagnosis:
Current medications:
How would you describe your faith?
*
Are you a member of a local church?
*
Yes
No
If yes, name and location of the church?
If yes, would you say you are actively involved in your church?
Yes
No
If yes, are you part of a small group community?
Yes
No
Briefly describe why you are seeking counseling at this time:
*
PRELIMINARY SELF-ASSESSMENT - Check all that apply:
*
I feel depressed
I feel anxious
I feel insecure
I feel inferior
I feel hopeless
I feel fearful
I feel angry
I struggle with anger
I feel sad
I think of suicide
I feel inadequate
I have obsessive thoughts
I struggle with compulsive behaviors
I struggle with lust
I struggle with worry
I struggle with doubt
I struggle with bitterness
I feel worthless
I have marital problems
I struggle as a parent
I drink too much
I struggle with alcoholism
I abuse prescription drugs
I use illegal drugs
I view pornography
I struggle sexually
I have been unfaithful to my spouse
My spouse has been unfaithful to me
I struggle to communicate effectively
My spouse struggles to communicate effectively
My faith is important in my life
I feel distant from God
I do not read my Bible often
I feel distant from Christian fellowship
I have been verbally abused
I have been verbally abusive
I have been physically abused
I have been physically abusive
I have been sexually abused
I have been sexually abusive
Submit
Should be Empty: