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
Please describe briefly your reason for seeking counseling at this time:
Approximately when did this situation begin?
Have you previously sought counseling assistance?
Please briefly describe that counseling, including its outcomes:
Any family history of (check all that apply):
Other problem behavior
Your history of use of alcohol and/or other drugs (except for prescribed medications):
Your school and work history:
Your spiritual/religious history (please include attendance and participation if applicable)
Your goals for counseling (what would you like your counselor to help you accomplish?)
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