Client Intake Form

Date

Referred by:

Thinklifechange Counselor*

Personal Information

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Phone*

Employer

Position

Gender:*

Age*

Date of Birth*

Relationship Status*

Religious Preference:*

Church you belong to:

Name and telephone number of significant other (or person to contact in case of emergency)*

Relationship to you:*

Phone*

Children’s names and ages:

Name	Age

Click the + to add additional rows.

I am seeking counseling and discipleship services for:*

Have you received counseling previously?*

When?*

Name of Counselor*

State in your own words why you are seeking counseling at this time:*

We do not give medical advice or recommendations about medications.

We are trained to use the Scriptures to address difficulties for those who seek help.

(Recommended reading materials will cost retail prices).