Christian Life Fellowship Biblical Lay Counseling and Discipleship Intake Form

Personal Data

Please make an entry for each section. Type NA if not applicable. For marriage counseling, we ask both spouses fill out the form separately.

Name

Date of birth

If a minor, name of parents/guardian

Requesting what type of counseling

Individual Premarital Marriage

Gender

Phone

May we leave a message?

Yes No

This address will receive a confirmation email

Address

Occupation

Employer

Referred by

How did you hear about us?

Emergency Contact Information

Name

Relationship

Phone

Marriage & Family Information

Are you

Single Married Separated Divorced

If married, please provide date of marriage, spouse's name, date of birth, address (if different), phone number

Have you been separated in your current marriage, yes or no? If yes, please explain

Have either of you ever filed for divorce, yes or no? If yes, please explain.

Have either you or your spouse been married before, yes or no? If yes, why did the marriage end?

If currently separated, how long have you been separated? What are/were the reasons?

Children: please list the name, age, and gender of each child.

Spiritual/Religious Information

Church Name

How many times do you attend each month?

Please list ministry involvement:

Have you received Jesus as your personal Savior, yes or no?

How would you define the gospel and what it means to be a Christian?

Have you been baptized, yes or no?

Health Information

Are you currently taking prescription medication, yes or no? If yes, please list name of medication, condition prescribed for, how long you have been taking each medication:

If you are NOT currently taking prescriptions, have you ever been prescribed medication to treat a mental health issue, yes or no? If yes, please list name of medication, condition prescribed for, length of time you took medication:

How would you describe your overall general physical health?

Excellent Average Poor

How often do you exercise?

3-5 times a week less than 3 times a week Never or occasionally

How is your sleep? (Please explain)

Do you have any mental health related concerns (anxiety, depression, OCD, bi-polar, etc.)? Please explain.

Do you currently struggle with suicidal thoughts, yes or no? In the past? Please explain.

Presenting Issues

Describe the current struggle for which you are seeking counseling.

What have you done about it? What has been most effective? What has been least effective?

Please describe any family history that might be pertinent to your reason for seeking counseling.

Any further information that we should know? (relationship in family of origin, significant losses or events etc.)

Special requests or accommodations:

Description

Please fill out this form and click submit. You will be contacted within 3 days of receipt of form. Counseling sessions are free, however we do request a one time $35 fee due at first appointment to cover the cost of resources and training. If this is a hardship for you, please contact the CLF office at 541.889.7264.

Christian Life Fellowship Biblical Lay Counseling and Discipleship Intake Form

Description

Please Fix the Following