Therapy Information Intake
This information will be handled with the same confidentiality as all other Protected Health Information received by Christian Counseling Associates, Inc. in Columbia, Maryland
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Full Name
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Your answer
Please describe briefly your reason for seeking counseling at this time:
Your answer
Approximately when did this situation begin?
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YYYY
Have you previously sought counseling assistance?
Yes
No
Clear selection
From whom?
Your answer
Please briefly describe that counseling, including its outcomes:
Your answer
Any family history of (check all that apply):
Alcohol/drug abuse
Sexual abuse
Family violence
Other problem behavior
Your history of use of alcohol and/or other drugs (except for prescribed medications):
Your answer
Your school and work history:
Your answer
Your spiritual/religious history (please include attendance and participation if applicable)
Your answer
Your goals for counseling (what would you like your counselor to help you accomplish?)
Your answer
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