Real Life Counseling Center Intake Form
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Name: *
Age: *
If the counselee is a minor (17 yrs. old or younger) please provide legal guardian's name and contact number: *
Address: *
Email:
Phone number: *
How did you hear about Real Life Counseling Center? *
Is there a day/time that works better for your appointment? *
Occupation: *
Employer:
Avg. number of hours worked per week: *
Please list any major health diagnoses/concerns: *
How would you rate your physical health? (1 being poor, 5 being excellent): *
How many hours do you sleep at night? *
Do you exercise regularly? *
Have you been to the doctor in the last year? *
Please list any medications you are currently taking and the condition for which they're prescribed:  *
Please describe the circumstances as to why you're seeking counseling: *
Have you had psychotherapy or counseling before? *
Has any legal action been taken or filed or is likely to be taken in the situation for which you are seeking counseling?  If yes, please explain: *
Have you ever suffered from a severe emotional upset, panic attack, nervous breakdown, etc? *
Have you ever been physically, sexually, or emotionally abused as a child or adult?  
Have you recently thought of harming someone else? *
Have you ever contemplated suicide or harming yourself?  If yes, please explain: *
Are you currently in danger or harming yourself or someone else? *
Are you currently affiliated with a local church?  If so, please provide the name of the church: *
On average, how often do you attend live worship services in your church each month? *
Do you have a personal relationship with Jesus Christ?  If so, please explain how/when you came to know Christ and what your relationship with Him looks like now: *
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