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 Phone 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.