Life Transformed Client Information Sheet
Please complete. It will only take 5-7 minutes.
Email address *
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Contact Phone *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Education level completed *
Your answer
Current Occupation *
Your answer
Are you currently involved in a faith community?
if so, where?
Your answer
Family of Origin
Father's Name *
Your answer
Mother's Name *
Your answer
are/were they... *
if divorced, how old were you?
Your answer
Step Father's Name(s) and how old were you?
Your answer
Step Mother's Name(s) and how old were you?
Your answer
Siblings and ages *
Your answer
Your Childhood Adverse Experiences (ACE) Calculator
While you were growing up, during your first 18 years of life:
**If you are under 18, choose NO for each response
1. Did a parent or other adult in the household often or very often: Swear at you, insult you, put you down, or humiliate you? OR... Act in a way that made you feel afraid that you might be physically hurt? *
2. Did a parent or other adult in the household often or very often: Push, grab, slap, or throw something at you? OR... Ever hit you so hard that you had marks or were injured? *
3. Did an adult or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way? OR... Attempt or actually have oral, anal, or vaginal intercourse with you? *
4. Did you often or very often feel that: No one in your family loved you or thought you were important or special? OR... Your family didn't look out for each other, feel close to each other, or support each other? *
5. Did you often or very often feel that: You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR... Your parents were too drunk or high to take care of you or take you to the doctor when you needed it? *
6. Were your parents ever separated or divorced? *
7. Was your mother/stepmother: often/very often pushed, grabbed, slapped or had something thrown at her? OR... Sometimes, often or very often kicked, bitten, hit with a fist or hit with something hard? OR... Ever repeatedly hit at least for a few minutes or threatened with a gun or knife? *
8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs? *
9. Was a household member depressed or mentally ill, or did a household member attempt suicide? *
10. Did a household member go to prison? *
Add up your "yes" answers. Your ACE score is: *
Adulthood
Current relationship status- check all that apply *
Required
Partner/Spouse's name and age- if no one currently, indicate with NA *
Your answer
Please list current and/or prior marriages, from when to when (in years)
Your answer
Children's Name(s) and Ages *
Your answer
Please specify what current medications or supplements you are taking, and for what purpose. *
Your answer
Have you received counseling or mental health services in the past? *
if yes, was it a positive experience?
What is the reason you are seeking counseling right now?
Your answer
How long do you expect to be in the counseling process for what you're addressing?
Your answer
Are you open to God's solution? *
I found your practice through
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Insurance Info
We are happy to come alongside and file any insurance claim on your behalf. Rev. Greg is an out of network provider for every carrier, so plan to make payment in full at the close of your appointment, and we will submit your claim for any benefit you may receive. We can also swipe a health savings account card, if you happen to have one.
Insurance company name and contact number
Your answer
Policy/Group/ID number
Your answer
Name of primary insured
Your answer
Confidentiality Covenant
The communication between client and counselor is considered confidential except as where required by law, i.e., where there is a threat of serious harm to self or others, such as, but not limited to, child abuse, suicide or homicide.
Only with your consent, you may allow your counselor to share your information and session notes with a third party medical or mental health provider for your treatment and care. Whatever information that may have been shared at that point will of course, be exempt.
By clicking "yes" below, I indicate that I understand my rights as a client, and agree to these terms and conditions. *
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