Client Intake Form Date MM slash DD slash YYYY Referred by: Thinklifechange Counselor*SelectDr. Kerry SkinnerAlison VeazeyHannah MergistLeslie BayneKaren de GraafWalter de GraafPersonal InformationName* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Employer Position Gender:* Male Female Age* Date of Birth* Relationship Status* Single Married Separated Divorced Widowed 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:NameAge Click the + to add additional rows.Counseling InformationI am seeking counseling and discipleship services for:* Individual Couple Family Group Have you received counseling previously?* No Yes 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). 87797 Share this:
