Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
###
####
Email Address
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Age
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Date of Birth
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MM
DD
YYYY
Gender
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Male
Female
Ethnicity
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African American (Black)
Asian
Caucasian (White)
Pacific Islander
Hispanic/Latino
American Indian or Alaska Native
Nationality
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How did you hear about us?
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Friend
Family
Social Media
Website
Do you currently attend church? If so, what ministries are you involved with and where do you attend?
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Occupation
How long have you been employed at your present job? Does it satisfy you?
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Please explain.
Have you served in the Military? If so, when and where?
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Briefly describe some of your hopes, dreams and goals for the future.
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How do you spend your free time?
What kind of fun is included in your life?
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With whom are you living?
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Give name, relationship and age
Are you responsible for aging parents?
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Brief details.
Briefly describe your spiritual background, if any.
Have you ever been involved in a cult?
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Have you ever been involved in occult activities?
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Check all that apply.
Have you received previous counseling? Was it helpful?
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Please explain.
How strongly do you want help for your current problems?
Check all that apply to you:
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Have you ever had drug (prescription, or other) or alcohol problems?
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Please explain.
Have you had any operations? Do they impact current problems?
When was the last time you felt well, both physically and emotionally, for a fair amount of time?
Briefly describe.
Name of current spouse/partner? How long have you known one another? Length of engagement? Years married?
Describe traits you like about this individual.
Traits you dislike
Is there anything you wish he/she would do less or more often?
How do you get along with your in-laws (parents/brothers/sisters)?
Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.? Briefly explain.
Name of prior spouse/partner, length of marriage, length of engagement and age at time of marriage.
Describe traits you liked about the person named above:
Dislike:
What was the primary reason why your marriage/relationship broke up?
List your children by name & age (all those living with you or elsewhere, including step, foster, adopted, and children lost through miscarriage, abortion, death)
Which child is most like you and why?
Which child is most different from you & why?
Which child is your favorite & why?
Do you have difficulty with any child?
How do your children relate to your spouse/partner?
What goals do you have for your children?
Father's name, current age, occupation?
Health
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Good
Average
Poor
Marital status
Single
Separated
Divoced
If divorced, how old were you and your reaction to the divorce?
If deceased, age at death & cause? Your age at time of death and your reaction to death?
Describe the kind of person your father was when you were younger.
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What did you like about your Dad?
Dislike about Dad?
What was his relationship to the children in the family?
His relationship with your mother?
Who was his favorite child, and why?
Mother's name, current age, occupation?
Health
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Good
Average
Poor
Marital Status
Married
Single
Separated
Divorced
If divorced, how old were you your reaction to the divorce?
If deceased, age at death & cause? Your age at time of death and your reaction to death?
Describe the kind of person your mother was when you were younger.
Describe her relationship with your father.
What did you like about your mom?
Dislike about mom?
Her relationship with the children in the family.
Who was her favorite child, and why?
List by name and age (all those who lived with you or elsewhere, adopted, step, miscarried, deceased.)
Describe your relationship with your siblings.
Which brother/sister was most like you, and why? Which was most different, and why?
Describe your mother's emotional and physical condition during her pregnancy with you.
What were your parents reaction to the news that you were going to be born?
Describe the atmosphere in your home when you were a child.
Was your home affected by alcoholism, drug addiction, mental disorder, etc.?
What were important values in your family?
Were you able to confide in your parents?
Describe how your parents disciplined you.
Was your childhood happy or unhappy?
Describe any childhood fears or conditions (e.g. bed-wetting, thumb-sucking)
First knowledge of: Sex, Sexual identity, Pornography
What was your parents' attitude toward sexuality (was there any discussion in the home?)
Were you molested as a child?
Have you ever experiences any trauma or anxiety arising from a sexual experience with the opposite sex?
Please explain.
Have you ever experienced any trauma or anxiety arising from a sexual experience with the same sex?
Please explain.
I understand that by checking this box I accept the Legal Liability Release.
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Date
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MM
DD
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Date
MM
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