Adult Intake Form
please fill out this form before receiving counseling services
Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
Address:
Your answer
Counseling I am seeking:
Required
Best number to reach you on:
Your answer
Secondary number:
Your answer
Can we leave a confidential voice mail?
Email address:
Your answer
How did you hear about the counseling program at Cumberland Community Church?
Your answer
Employment Status:
I am:
Name of spouse:
Your answer
How many people live in your household?
Your answer
Do you have any children/step children?
Emergency Contact name:
Your answer
Emergency Contact relationship:
Your answer
Emergency Contact phone number:
Your answer
Please list any anti-depressant or anti-anxiety medications you are currently taking (or write n/a):
Your answer
Please list any major medical problems you currently have (or write n/a):
Your answer
Have you received counseling services from Cumberland Community Church before?
Are you interested in group counseling?
If you are interested in a group, what kind of group would you want to participate in? (or write n/a)
Your answer
Please describe your current reasons for seeking counseling at this time. If there is a particular event which triggered your decision, please list this event:
Your answer
What do you hope to achieve/address in counseling?
Your answer
What are your religious or spiritual beliefs?
Your answer
Have you ever strongly considered or attempted taking your own life?
Are you considering taking your life currently?
Is there anything else you’d like the clinician to know? (or write n/a)
Your answer
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