Adult Intake Form
please fill out this form before receiving counseling services
Name:
Your answer
Date of Birth: *
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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
Approx. annual income?
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