Primary Client Registration Form

Please fill out the form below.

If you would prefer to use a hard copy of the form and send it in by mail, click the button to download a PDF copy.

PDF Registration Form

Primary Client Registration Form

PERSONAL DATA INVENTORY

First Name

Date

Last Name

Email Address

Phone

Date of Birth

Address

CURRENT ISSUES

Main reason(s) for contacting our office:

How long has this been a problem?

Have you Sought counseling for this before? If yes, where, when and with whom?

Do you have family members that have sought counseling or been treated for emotional issues? If yes, briefly explain:

Have you experienced any major loss, trauma, or been the victim of any emotional or physical abuse? If yes, describe:

Please describe your current physical health or issues with your health:

Describe your physical/medical history. If you are currently under the care of a physician, what is the treatment addressing?

Please list any medications you are currently taking: Medication Name Amount per Day

Describe any recent and major changes in your weight or eating habits?

FAMILY HISTORY

List all those living at your address: name, age, and relationship to you?

MARITAL STATUS

Click One

Single

Married

Separated

Divorced

Widowed

Cohabitating

If married, what is your spouse’s first name

If they are employed, what is their occupation

Briefly describe your marital history

Are your biological parents living? If yes, describe your relationship with them:

YOUR FAITH JOURNEY

Are you a Christian? (Y) (N) (circle one) If yes, for how long?

If no, what do you believe about life/death?

Why did you seek Christian Counseling?

Briefly describe your prayer life

Do you attend church regularly?

If yes, which church?

Do you read the Bible regularly?

How would you describe your relationship with the Lord?

SUBSTANCE USE/ABUSE

How would you describe your use of alcohol?

Never have used it

Used to use it but no more

Drink Occasionally

Drink Often

I may have a drinking problem

I am an alcoholic

Have you ever used illegal drugs? If yes, which drug(s) and how long ago?

Do you have a family history of drug/alcohol use/abuse? If yes, describe:

YOUR EDUCATION

Highest level of education completed

GED

High School

vocational training

College

Advanced degree(s)

Year of last graduation

MILITARY SERVICE

Branch of service and type of discharge :

Are you a combat veteran? If yes, which theater?

Did you sustain any injuries associated with your service? If yes, what type?

Did you receive any disability associated with the injury?

EMPLOYMENT HISTORY

Are you currently employed? If yes, where and for how long?

What other jobs have you held in the past 3 years?

LEGAL HISTORY

Are you currently involved in any legal actions that could influence your counseling? Please describe:

Do you anticipate asking your counselor to testify?

DISABILITIES

Have you ever been diagnosed by a medical professional as having a disability? If yes, please describe:

What special assistance/accommodations do you require, if any?

EMERGENCY CONTACT

Who do you designate as an emergency contact? Please give name and number:

OUR FEE SCHEDULE

Our sliding scale fee schedule is based on annual family income. Please check the level that applies.

Up to $50,00 per year - $55.00 per session
Up to $60,000 - $65.00 per session
Up to $70,000 - $75.00 per session
Up to $80,000 - $85.00 per session
Up to $90,000 - $95.00 per session

We do not bill any insurance for our services, but we can provide an insurance coded receipt. Some insurance companies may reimburse for services. Most will not.

Our counselors adhere to biblical principles in all approaches and methods to counseling. We provide counseling services that address but will not necessarily be limited to:

Depression / Anxiety
Pornography and Other Sexual Addictions
Premarital Counseling
Planned and Unplanned Career Changes
Parenting Skills
Anger / Bitterness
Childhood Behavioral Issues

Family Conflict and Communication Difficulties
Physical, Emotional, and Sexual Abuse
Substance Abuse
Divorce Care
Grief and Suffering
Lifes Changes Due to Health Issues
Crises of Faith