Full Restoration Christian Counseling Intake Form
Pre-Marital, Marriage, Family, Adolescence, Individuals & Groups
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
example@example.com
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Primary Care Provider
Referral Name
First Name
Last Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Please check all the apply
None
Anxiety
Depression
Anger
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
Are you currently taking prescription medication?
Yes
No
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Have you had any surgeries in the past 5 years?
Yes
No
Please specify:
Family history
Alcoholism
Depression
Diabetes
Drug Addition
Childhood Trama
Anger Issues
Other
Mental Health History
Why are you seeking counseling?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Yes
No
Therapist Name
First Name
Last Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Appointment
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: