ENROLLMENT INFORMATION

The information asked below is to allow us to more quickly understand you and your reason for requesting
counsel and to enable us to help you more expediently. Please fill out all forms as completely as possible.
All information is held in the strictest confidence and cannot be divulged to anyone without your written
permission.
DEMOGRAPHIC DATA
Name ________________________________________________
Address Phone (Wk) _____________________________

Date _____________________

(Home) _________________________

Date of Birth _________________________________________

Age _____________________

City ______________________________ State ________ Zip _________ S.S. # ________________

Place of Birth ________________________________ Nationality ______________ Sex ___________
Religion _______________________ Place of Employment __________________________________
FAMILY BACKGROUND
Do you have children? ___________________________
List names:

How many? ______________________

How many are living at home? _______

______________________________________________________

Age ______________

______________________________________________________

Age ______________

______________________________________________________

Age ______________

______________________________________________________

Age ______________

How many children at home are from a previous marriage? ____________________________________

Fathers name _______________________________________ Where does he live? _______________
His occupation ______________________________________ Age ______ Living/Deceased _________
His health? _________________________________________ Last saw him when? ________________
Mothers name _______________________________________ Where does she live? ______________
Her occupation _____________________________________ Age ______ Living/Deceased _________
Her health? __________________________________________ Last saw her when? _______________
Religion raised in, if any? _______________________________________________________________
Was your PARENTAL HOME EVER BROKEN BY:
Death _______________ Your age then? _________ How did you feel? _________________________
Divorce ______________ Your age then? ________ How did you feel? _________________________
Separation ____________ Your age then? ________ How did you feel? ________________________

Desertion _____________ Your age then? ________ How did you feel? ________________________
Which parent in the above was lost from the home? __________________________________________
Did your mother or father remarry? ___________________________ Your age then? ______________
How did you feel about your stepparent? ___________________________________________________
Did you have a good or bad relationship with your:
Father ________________________________ Explain: ______________________________________
____________________________________________________________________________________
Mother_______________________________ Explain: _______________________________________
_____________________________________________________________________________________
Brother or Sister _______________________ Explain: _______________________________________
____________________________________________________________________________________
Was PARENTAL FAMILY a closely-knit family? _______________ Is it close now ______________?
Did your family change residences (move) often? ____________________________________________
Why? _______________________________________________________________________________
How many schools did you attend prior to any college? ________________________________________
MARITAL BACKGROUND
Marital Status: (Please check)

Single __________ Married ________ Divorced ___________

Separated ________ Widow(er) ______ Cohabitating ________

Spouses Name? _______________________________________________________________________

Married? ______________________

How long? __________________________________________

Spouse Deceased? ______________

How long? ___________________________________

Divorced? ____________________

How long? ___________________________________

Annulled? ____________________

How long? ___________________________________

If previously married, please give dates and how dissolved ____________________________________

____________________________________________________________________________________
____________________________________________________________________________________
Describe your relationship with your spouse (if not married, your parents, etc.) ___________________
____________________________________________________________________________________
____________________________________________________________________________________

ORDER BIRTH
What is your placement in your family? 1 2 3 4 5 6 7 8 9 10 11 12 (circle one)
Brothers ages ________, _______, _______, _______, _________, _______, _______, ________.
Sisters ages ________, _______, _______, _______, _________, _______, _______, ________.
Are you adopted? _______________ Are any brothers or sisters adopted? ____________________
If yes, what are their ages and how many are there? _______, _______, _______, _______, _______,
If a twin, are you identical? ___________________
MILITARY SERVICE RECORD
Have you ever been in the military service? Yes ___________ No ___________
If yes, what branch? __________________ Were you in combat? Yes _____________ No __________
In Vietnam? Yes __________ No _________
Any military honors or medals? ___________________________________________________________
Type of discharge? ________________________________
EDUCATION
What is the highest grade you completed in school and in what year? ____________________________
What is the highest degree you have received? (Circle one)
AA BAIVS MAIMS MSW MTh MDiv MBA RB LPN MD DD ThD PhD Other: ___________________
What was your major? _______________________ Minor? ___________________________________
OCCUPATION
Your occupation: ______________________________________________________________________
Your employer: ____________________________________________ How long? _________________
Employers address: ___________________________________________________________________
Employers telephone number: ___________________________________________________________
What type of work do you do? ___________________________________________________________
If you could be anything or anyone you wanted, who or what would you be? (be specific) ____________
_____________________________________________________________________________________
_____________________________________________________________________________________
Spouses occupation: ___________________________________________________________________
Spouses work telephone number: _________________________

PERSONAL INFORMATION
1. Presently I believe my spiritual condition is: (Circle one)

1. Poor

2. Fair

3. Average

4. Good

5. Excellent

Presently I believe my physical condition is: (Circle one)

1. Poor

2. Fair

3. Average

4. Good

5. Excellent

Presently I believe my emotional condition is: (Circle one)

1. Poor

2. Fair

3. Average

4. Good

5. Excellent

2. Check the items that best describe or relate to the reason you need to receive counseling:
Bereavement _________

Religious doubts _________

Relationship with parents ________

Depression ___________

Marriage problems _________ Relationship with children ________

Hatred _______________

Bitterness ________________ Relationship with others _________

Anxiety ______________

Sexual concerns ___________ Loss of faith in God _____________

Nervousness _________

Adultery _________________ Loss of faith in self ______________

Fear _________________

Impotency _______________ Loss of faith in others ____________

Self-doubt ___________

Frigidity _________________ Loss of hope ___________________

Guilt ________________

Homosexuality ____________ Loss of meaning ________________

Suicidal _____________

Anger with God ___________ Loss of feelings or thoughts _______

Loneliness ___________

Loss of love ______________ Loss of self-respect _____________

If a female, have you had any discontinued pregnancies? ________________________________

Have you ever been arrested for other than a traffic violation? ____________________________
______________________________________________________________________________
How old were you when you left your parental home? __________________________________
Have you ever been institutionalized for any problem?__________________________________
______________________________________________________________________________
3. Have you sought help previously? (from whom, when, the outcome)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Please check any of the following symptoms or conditions you have had or are now experiencing:
CONDITION

PAST

PRESENT

CONDITION

PAST

PRESENT

Mood highs or lows

Weight loss or gain
Appetite change
Drug usage
Cigarette usage
Tobacco usage
Irritability
Excessive stress
Crying spells
Phobias or fears
Hallucinations
Confusion
Low self-esteem
Compulsion
Depression
Extreme nervousness

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Insomnia (Can't sleep)

Excessive worries
Difficulty concentrating
Hearing unseen voices
Frequent loss of temper
Acting out violence
Frequent employment changes
Frequent residence changes
Bed-wetting past age 6
Fire setting past age 6
Blaming others frequently
Lack of sexuality awareness
Spiritual confusion
Thoughts of suicide
Inability to comprehend reading
Inability to comprehend math

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Lack of motivation

_______

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Inability to express self

_______ ________

Excessive drinking
Indecisiveness
Loss of memory
Fantasizing

_______
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Involvement with the occult

Personal sexual abuse
Physical abuse of children
Physical abuse of others

_______
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BACKGROUND INFORMATION
1. How long has 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? ______________________
List their names and purposes? _________________________________________________
___________________________________________________________________________
5. Do you take vitamins? ___________

What kind? ________________________________

6. Your favorite food? __________________________________________________________

7. Your favorite dessert? ________________________________________________________

How often do you eat it? ______________________________________________________

8. Do you snack often? ________________ On what? ________________________________
9. Do you use alcoholic beverage? (Check One)
None _______

Some ______ Moderately _______

10. Is there a family history of alcoholism? _________

Other ______

Every day ______

Who? ________________________

11. Do you drink coffee? ________ Decaffeinated ________

Regular ___________

How many cups per day? Less than 3 ____ More than 3 ____ More than 6 ___ (Check one)
12. 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)
a. What church do you now attend, if any? ____________________________________
b. Are you a regular ____ frequent _____ occasional _____ infrequent _____ attendee?
15. What are your two favorite colors? ____________________ and ______________________
16. Have you ever thought of committing suicide? __________
If yes, explain: ______________________________________________________________
___________________________________________________________________________
17. Have you ever attempted suicide? ____________ When? ___________________________
18. Do you ever think that perhaps youre going crazy? _________ If yes, explain: ___________
___________________________________________________________________________
___________________________________________________________________________
19. Do you ever simply want to run away? ______ If yes, explain: ________________________
___________________________________________________________________________
20. Do you look forward to the future? Yes ________ No _______
21. How do you feel about the past?
__ Good __ Ok __ Guilty __ Bitter __ Angry __ Confused __ Wish you could change it.

22. What time period do you think about the most?

Past ____________

Present ____________________

Future ______________

Number in order of importance: 1, 2, 3, (#1 being most important).

23. Is there a family history of physical or emotional abuse? _________ If yes, please explain:
___________________________________________________________________________
___________________________________________________________________________
24. Were you ever sexually abused or molested? __________ If yes, by whom? ____________
25. Do you believe your only problem is the behavior of someone else? __________________
If yes, please explain: _________________________________________________________
26. In your own words, complete this sentence: Sex is __________________________________
___________________________________________________________________________
27. Are vitamins and minerals important? _____________ Why? ________________________
___________________________________________________________________________
So that we may understand your problem fully, please state in your own 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 life.

Signed: __________________________________________________