C3 Counseling Screening Assessment
Thank you for taking a meaningful step toward your well-being, we're so happy you are here. This short assessment helps us understand whether Pastoral counseling or a check-in from our Clinical team will best support you right now. Your information is confidential within our care team except as required by law. If you are in crisis or immediate danger, call 911 or 988.
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First Name
*
Last Name
*
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Are you a member or regular attendee of The Campus Community Church (C3)?
*
Yes
No
Visiting
Briefly describe what brought you to seek counseling today.
*
0/25
Wellness & Emotional Health
I feel overwhelmed by stress
*
Never
Rarely
Sometimes
Often
Almost always
I am experiencing persistent sadness, depression, or hopelessness
*
Never
Rarely
Sometimes
Often
Almost always
I have difficulty sleeping due to emotional or mental strain
*
Never
Rarely
Sometimes
Often
Almost always
I am struggling with anger, irritability, or emotional control
*
Never
Rarely
Sometimes
Often
Almost always
I feel anxious, fearful, or constantly on edge
*
Never
Rarely
Sometimes
Often
Almost always
I am experiencing conflict in significant relationships
*
Never
Rarely
Sometimes
Often
Almost always
I feel disconnected or numb in my daily life
*
Never
Rarely
Sometimes
Often
Almost always
I am using substances (alcohol or drugs) to cope with my emotions
*
Never
Rarely
Sometimes
Often
Almost always
Stressors
I have experienced a significant life crisis or trauma recently
*
No
Yes
I have a history of trauma (emotional, sexual, physical, etc)
*
No
Yes
Safety
Are you currently experiencing thoughts of harming yourself or others?
*
Never
Rarely
Sometimes
Often
Almost always
Total Score
I understand and consent to the use of my information for pastoral care or clinical triage.
*
I agree
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