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Basic Info

Today's Date

Name:

Email:

Phone:

Address:

State:

Zip:

Birthdate:

Age:

Occupation:

Employer:

Gender:

Education:

Other Training:

Hobbies:

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Emergency Contact

Emergency Contact:

Telephone:

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Referral

Referred By:

Relationship:

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Marital Information

Who shares your household:

Marital Status

Name of Spouse:

Address of Spouse:

Telephone of Spouse:

Occupation of Spouse:

Religion of Spouse:

Education of Spouse:

Does your spouse know you are coming for counseling?

Please provide information about previous marriages if applicable:

Please list the names and ages of any children:

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History

If raised by someone other than your own parents, briefly explain:

How many siblings do you have and where are you in order of birth::

Was there anything unusual in your childhood or adolescent years:

If yes, briefly describe:

Have you dealt with severe emotional struggles, abuse, or trauma in the past:

If yes, briefly describe:

Have you ever wanted to harm yourself of others:

If yes, briefly explain:

Have you ever participated in counseling or therapy in the past:

Please list counselor/therapist and dates:

What was the result of your counseling:

Please select any of the following words that best describe you now::

Self-confident

Anxious

Moody

Often Sad

Impulsive

Exicitable

Calm

Shy

Fearful

Introvert

Extrovert

Likable

Lonely

Bitter

Angry

List any fears you have:

Have you ever been arrested:

Please explain the reason for your arrest:

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Health Information

Rate your health:

When was your last physical:

Are you taking prescription drugs:

If you are taking prescription drugs, please list them:

How often do you consume alcohol:

In the past 5 years, have you taken illegal drugs or abused prescriptions drugs:

Approximately how much sleep to you get each night:

When do you usually go to sleep and get up:

Have you recently lost or gained a significant amount of weight:

Do you have any chronic medical conditions:

If you have chronic medical conditions, please list them:

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Religious Background

What church (if any) did you attend in childhood:

How long have you attended VBVF:

Do you believe in God:

How often do you pray to God:

How often do you read the Bible:

Do you know for certain if you were to die today, you would go to heaven:

What would you say if you died today and God asked you why should you be allowed in heaven:

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Other

Are you involved in any legal action at this time:

If you are involved in any legal action, please explain:

How would you describe the issues which brought you here:

How have you tried to deal with them:

What are your expectations and goals in coming to counseling at VBVF:

What prompted you to come at this time:

Is there any other information you would like to share or think we should know:

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