Client Intake Form Date Date Format: MM slash DD slash YYYY Referred by:Thinklifechange Counselor*SelectDr. Kerry SkinnerAlison VeazeyHannah MergistBrian EdmondLeslie BaynePersonal InformationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*EmployerPositionGender:*MaleFemaleAge*Date of Birth*Relationship Status*SingleMarriedSeparatedDivorcedWidowedReligious 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?*NoYesWhen?*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). Share this: