Counseling Enrollment Form

IMPORTANT: Please make sure we have spoken

and I have accepted you as a client before you begin filling out this form.

Thank you ahead of time for filling out the following information. It will help me to understand your situation and help you reach your goals as quickly as possible.

Name*

Date of birth*

Email address

Mobile phone number*

Work phone number

Best number to reach you

Street address

City

State + ZIP code

Today's Date*

Month-Day-Year

What type of counseling are you seeking?

Child/Teen

Family

Both Family & Child

Individual

Other Information

Spouse / Significant other

Spouse / Significant other - Address

Marital Status

Person to contact in case of emergency:

Emergency contact's mobile phone number:

Do you have children? If so, list name(s) and age(s).

Names and ages of all people living in your household:

Do you have pets? If so, list name(s), type, and how long with you.

What is your highest level of education?

What is your occupation and employer?

Whose idea was counseling?

Mine

Court

Somebody else

Describe yourself in a few sentences:

What are the primary issues for which you are seeking counseling?

What are the most important things you think I should know about you?

In what ways have you attempted to cope with these issues?

If counseling were successful, how would things be different?

Have you sought counseling previously? If so, what was helpful and not helpful?

Do you have any fears or concerns regarding counseling?

What religion were you raised in, if any?

Current religious or spiritual preference:

Level of importance of religion to you:

What time period do you find yourself thinking about most?

Do you look forward to the future?

List the people in your life that are most supportive to you.

List any activities, groups or hobbies that you enjoy.

I would like to thank the person who referred you. Please type in their name here.

Thank you for taking the time to complete the counseling enrollment form. After clicking 'Submit' below, you will be redirected to the 'Informed Consent & Office Policies' form to read, review and acknowledge. This will complete your counseling registration process. Thank you!

*Counseling Enrollment Form*

Other Information

Counseling Enrollment Form