ROLLMENT INFORMATION Ihe information azkeil below is 10 alleww us to move qnick ly understand you atid your reason for requesting counsel and lo coatsle us fo lielp you more expediontly, Pieare fill cut all forme a3 completely 2s possibls. 41 information is held in the strictest confidence and cannot be divulged to anyone without your wrilien permission, DEMOGRAPULE DATA Name 7 _ Date Address Lbones: (WK) (Home) - Date of Birth Age _ City State Zp s8e Place of Birth Navionality Sex Religion __Hace of Employment FAMILY BACKGROUND. Tyo you have ehildren? __ - Tew Many? Lisi Names: How many are living at hone? Age — - Ago Age - — Age Tow many childrey ai horus ere them a previous: mastic? . __ Father's Name Where does ne tive? His occupation: Aw ivingMeceased, His health? Las saw him when? ‘Mother's Name, . ‘Where does she tive? Her oveupation: . Age ___ Living/Deecascal, Ter healt? _ __. Vast saw her when! Religion raised in, ifaay: - a Was your PARENTAL HOME EVER BROKEN BY: Death ‘Your age then? Low did you feel? Divorce, Your age then’? How dic you fisel? Separation ___ Your age then’? Tews did you feet? Mesertion __ Yorr age then? _____ How did yeu feel? PutWhich parent in the above was lost from the horuc? Did you mother or father remarry? _. Your age then? How did you (eel about your stepparent? Did you have good or bad welationship with your: Father . Explain: Mother Explain _ Brothers or Sisters _ Explain Was PARENTAL FAMILY a elosely-knit farnil Is it close now? Did your family change residences (move) often? why? How snany schools did you attend prior to any college? MARITAL BACKGROUND Marital Status: (Please check) Single Maricd Divorced Separated — Widower) Cobabitating ‘Spouse's Name? Married? Vow long? _ Spouse Meceused? How Long? _ Divorced? _ _ How long? _ Ammulled? How tong oo If previously married, please sive dates and how dissolved. revelBIRTH ORDER What is your placement in your family? 12 34 5 6 7 89 10 11 12 (Circle one} Brothers! ages : Sisters ages _ : oe _ Ase you adopted? Are any brothers or sisters adopted? _ IL yes, what are their ages and how many are there? _ : Ifa twin, ate you identical? MILITARY SERVICE Haye you ever been in the military service? Yes No___ i yes, what brane Were you in combat? Yes No In Vietnam? “Yes No Any military boners or medals? Type of discharge? EDUCATION ‘What is the highest grade you comploted in schoo! and in whal year? What is the highest degree you have received? (Circle one) © AA BAIBS MAIMS MSW MTh MDiy MBA RN LPN MD D1) Thi) PhD Other: ‘What was your major? Minor? OCCUPATION ‘Your occupation: a Your employer Employer's address: Employer's telephone number ‘What type of work do you do? _ If you cemld be anything or anyone you wanted, who ar what would you be? (be specific) Spouse's oveupation: Spouse's work telephone number: estePERSONAL INFORMATION 1. Presently [ believe my spititual condition is: (Circle one) 1. Poor 2. Fair 3. Average 4, Good 3. Excellem Presently | believe my physical condition is: (Crete one} 1. Pear 2. Fair 3. Average 4. Good 5. Hxcelfent Presently L believe any emotional condition is: (Cirele one) 1. Poor 2. Pair 3. Average 4, Good 5. xecHent 2. Check the items that best describe or retate to the reason you aved ta soceive counseling: Bereavement ___ Religious doubts Relationship with parents Depression Marriage problems __Relationship with children Hatred Bittemess Relationship with others Anxiety Sexual concerns Loss of faith in God Nervonsness Adultery Loss of faith in set? Fear Impotency Loss of faith in others Selédoubt __CTrrigidity Loss of hope Guile Homosexuality Loss of meaning Suicidal Anger with Gad Loss of feelings or thaughts Loneliness Loss nf love Loss of self-respect Ifa female, have you had any discontinued pregnancies? Have you ever been arrested for other than a traffic violation? Tlow old were you when you Jeft your parental home? Have you ever been institutionalized for eny problem’? 3, Have you sought belp previously? (from whom, when, the outcome?)Please check any of ihe following symptoms or conditions you PAST PRESENT CONDITION Mood highs or lows ‘Weight loss or gain .... Appetite change Drug usage Cigarerte nsages Tobacco usa Irritability . Excessive stress Crying spells .. Phobias or fears Hallucinations Confusion . Low self-esteem . Compnlsion 2... Depression Extreme nervousness: Lack of motivation Excessive drinking Indevisiveness 20... Loss of memory .. Fantasizing CONDITION: pas Insomnia (Can't sleep). Excessive worries .... Difficulty concentrating Itearing unseen voices Frequent loss of temper . “Acting out violence . Frequent emplovment changes Troquent residence changes . Red-werting past age 6 . Fire selting past age 6 Blaming others frequently Lack of sexuality awareness Spiritual confusion . ‘Thoughts ol suicide .. Inability to comprehend reading Inability to comprehend math Inabilily to express self. Involvement with the occult. Personal sexual abuse .. Physical abuse of children Physical abuse of others BACKGROUND INFORMATION 1. How long his it been since you had a complete physical examination? . 2. What physical disorder do you have, if any? 3. How many schools did you attend prior to any college? 4. Do you take medications? __ Lise their names and purposes: 5. Do you tale vitamins? 6. Your favorite food? What kind? —LY.cnr famorile dessert? __. ¢ had or are now experiencing:How often iio you est it? 8. Do you snack often? On what? 9. Do you use aleoholie beverages? (Check Ons) None Some___Moderaiely = Often Every day 10, Is there a family histery of aleoholism? Whe? L1, Do you drink coffee? Devaffeiaated___ Regular How many cups per day? Less thm 3___ More than 3_) More-than 6 (Check one) 72. Do you use tobacco regularly? NO. Some Moderately: Heavy __ (Check one) 13. Describe yourself in a few sentences. 14, Are you a Christian? Yes ____ No Not sure _____ (Check one) 8. What church do you now attend, if any? b. Areyoua regular frequent oceasional__ infrequent attendee? 15. What are your two favorite colors? and 16, Have you ever thought of committing suicide? Hfyes, explain: 12, Have you ever attempted suicide? When’? __ 18. Do you ever think that perhaps you're going erazy? If, yes, explain: 19. Do you ever simply want io runaway? —__ Tf yes, explain: 20, Do you loek forward (ss the future? Yes No “21. How do-you feel about the past? __Gcod__OK Guilty Bitter Angry _ Confused __ Wish you could change ft.22, What tine period do you think about the most? Pest Present Future Number in order of importance: 1, 2, 3, 1 being most important). 23. Je there a family history of physical or emotional abuse? Ifyes, please explain: 24, Were you ever sexually abused or molested? Iyes. by whom? ta 5, Do you believe “your only proflem" is the behavier of saimcone else? Ayes, please explain: 26. In your own words, complete this sentence: Sex is 27, Are viamins and mincrals impostant? Why? So that we may understand your problems fully, please staie in your ewa words the life area you need answers to and why you chose a Christian mental health professional. MISCELLANEOUS INFORMATION If referred here, by whom? _ . ‘You are responsible for any decisions you make regarding your Ii Signed: