CLIENT CONSULTATION

Client Consultation
Name*

First NameLast Name
D.O.B.*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
May I leave a general voicemail?*

YesNo
May I text an appointment reminder?*

YesNo
Marital Status*

SingleSingle in relationshipEngagedMarriedSeparatedDivorcedWidowed
Name of spouse or significant other:
Will your spouse or significant other be attending counseling?*

YesNo
Children (names/ages):
Occupation:*
Employer:
In the event of an emergency, I give ResoluteBC permission to contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to you:*
How did you hear about ResoluteBC?*
Have you had previous counseling?*

YesNo
If yes, with whom? (name/city)
Have you ever been hospitalized for a psychiatric condition?*

YesNo
If yes, please describe:
Diagnosis:
Current medications:
How would you describe your faith?*
Are you a member of a local church?*

YesNo
If yes, name and location of the church?
If yes, would you say you are actively involved in your church?

YesNo
If yes, are you part of a small group community?

YesNo
Briefly describe why you are seeking counseling at this time:*
PRELIMINARY SELF-ASSESSMENT - Check all that apply:*

I feel depressedI feel anxiousI feel insecureI feel inferiorI feel hopelessI feel fearfulI feel angryI struggle with angerI feel sadI think of suicideI feel inadequateI have obsessive thoughtsI struggle with compulsive behaviorsI struggle with lustI struggle with worryI struggle with doubtI struggle with bitternessI feel worthlessI have marital problemsI struggle as a parentI drink too muchI struggle with alcoholismI abuse prescription drugsI use illegal drugsI view pornographyI struggle sexuallyI have been unfaithful to my spouseMy spouse has been unfaithful to meI struggle to communicate effectivelyMy spouse struggles to communicate effectivelyMy faith is important in my lifeI feel distant from GodI do not read my Bible oftenI feel distant from Christian fellowshipI have been verbally abusedI have been verbally abusiveI have been physically abusedI have been physically abusiveI have been sexually abusedI have been sexually abusive
Should be Empty:

Client Consultation