Christ Covenant Church Counseling Intake Information

The information you provide is strictly confidential

This form must be completed and submitted prior to your session

Name

Birth Date

Sex

Street Address

City

State

Zip

Home Phone

Cell

Business Phone

Email *

Describe Your Health

• Very Good
• Good
• Average
• Poor

Marriage & Family Relationships

• Single
• Steady Dating
• Married
• Separated
• Divorced
• Widowed

Nearest Relative/Friend in case of emergency

Name, Address, Phone Number

Do you currently attend Christ Covenant Church regularly?

• Yes
• No

Are you a member of Christ Covenant Church?

• Yes
• No

How Often Do You Read The Bible?

• Never
• Occasionally
• Often
• Daily

Problem Checklist

• Addiction/s
• Anger
• Anxiety
• Apathy
• Appetite
• Bitterness
• Change in Lifestyle
• Children
• Depression
• Deception
• Envy
• Fear
• Finances
• Forgiveness
• Guilt
• Health
• Homosexuality
• In-Laws
• Memory
• Moodiness
• Rebellion
• Religious
• Sex
• Sleep
• Spousal Abuse
• Vice/s

Current Reason For Seeking Counseling and What Issues You Are Hoping To Discuss?

Signature *

Date *

Submit