Phone number *
Phone type Mobile Home Work Other
Is this counseling request for you or for someone else? If someone else, please share the person's name and his/her relationship to you. *
Are you currently having suicidal thoughts? *
Select… Yes No
Have you ever attempted suicide? *
Select… Yes No
Do you have thoughts or urges to harm others? *
Select… Yes No
Do you have a salvation relationship with Jesus Christ? *
Select… Yes No
Do you attend church regularly? *
Select… Yes No
Please check any of the following that might apply.
Please check any of the following you have experienced in the past six months.
What is your current occupation? What do you do? How long have you been doing it? *
What is your level of education? Highest grade/degree and type of degree. *
Describe your current living situation. Do you live alone, with others, with family, etc. *
If you are in a relationship, please describe the nature of the relationship and months or years together. *
Is there a history of mental illness in your family? *
Select… Yes No
Have you ever been hospitalized for a psychiatric issue? *
Select… Yes No
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can. *
Do you use recreational drugs? *
Select… Yes No
Do you drink alcohol? *
Select… Yes No
Who is your primary care physician? Please include type of MD, name and phone number. *
Are you taking any prescription medications or supplements? *
Select… Yes No
Have you seen a mental health professional before? *
Select… Yes No
What are your goals for counseling? *
What else would you like me to know?
Confidential / Counseling Groups *
Would you be interested in any of these groups? Select as many as you like.
Personal Growth / Enrichment Classes *
Would you be interested in any of these classes? Select as many as you like.
Submit A copy of your responses will be sent to your email address.
