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CHM Biblical Counseling Intake Form
Thank you for choosing CHM for Biblical Counseling! Please complete all answers to the best of your ability.
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Last Name
*
Your answer
First Name
*
Your answer
How did you hear about Choosing Him Ministries?
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone Number
*
Your answer
Emergency Contact: Name (Last, First)
Your answer
Emergency Contact: Relationship to Client
Your answer
Emergency Contact: Phone Number
Your answer
Marital Status
*
Married
Single
Divorced
Widowed
Other
Availability for Counseling Sessions:
*
Weekday Daytime (9am-3pm)
Weekday Evening (4pm-7pm)
Online Only
Anytime
Other:
Required
Seeking counseling in the following area(s):
Anxiety
Depression
Grief/Loss
Marriage/Family
Spiritual Discipleship
Career Transition
Stress Management
Have you ever utilized counseling services in the past? If so, please explain.
*
Your answer
Are you currently on any prescribed medication? If yes, please list all. If no, type "N/A"
*
Your answer
What are your primary goals for counseling with CHM?
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Your answer
Do you have any other pertinent information you would like to share?
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Your answer
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