LTCC Client Information Sheet
Submit this form with test data, and Form Publisher will generate a test invoice for you that you will receive via email. You can then edit all the settings you want to customize your workflow.
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E-mailadres *
First Name *
Last Name *
Age *
Contact Phone *
Street Address *
City *
State *
Zip *
Education level completed *
Current Occupation *
Are you currently involved in a faith community?
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if so, where?
Family of Origin
Father's Name *
Mother's Name *
are/were they... *
if divorced, how old were you?
Step Father's Name(s) and how old were you?
Step Mother's Name(s) and how old were you?
Siblings and ages *
Your Childhood Adverse Experiences (ACE) Calculator
While you were growing up, during your first 18 years of life:
**If you are under 18, choose NO for each response
1. Did a parent or other adult in the household often or very often: Swear at you, insult you, put you down, or humiliate you? OR... Act in a way that made you feel afraid that you might be physically hurt? *
2. Did a parent or other adult in the household often or very often: Push, grab, slap, or throw something at you? OR... Ever hit you so hard that you had marks or were injured? *
3. Did an adult or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way? OR... Attempt or actually have oral, anal, or vaginal intercourse with you? *
4. Did you often or very often feel that: No one in your family loved you or thought you were important or special? OR... Your family didn't look out for each other, feel close to each other, or support each other? *
5. Did you often or very often feel that: You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR... Your parents were too drunk or high to take care of you or take you to the doctor when you needed it? *
6. Were your parents ever separated or divorced? *
7. Was your mother/stepmother: often/very often pushed, grabbed, slapped or had something thrown at her? OR... Sometimes, often or very often kicked, bitten, hit with a fist or hit with something hard? OR... Ever repeatedly hit at least for a few minutes or threatened with a gun or knife? *
8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs? *
9. Was a household member depressed or mentally ill, or did a household member attempt suicide? *
10. Did a household member go to prison? *
Add up your "yes" answers. Your ACE score is: *
Adulthood
Current relationship status- check all that apply *
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Partner/Spouse's name and age- if no one currently, indicate with NA *
Please list CURRENT (with anniversary) and/or prior marriages, from when to when (in years)
Children's Name(s) and Ages *
Please specify what current medications or supplements you are taking, and for what purpose. *
Have you received counseling or mental health services in the past? *
if yes, was it a positive experience?
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What is the reason you are seeking counseling right now?
How long do you expect to be in the counseling process for what you're addressing?
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Are you open to God's solution? *
I found your practice through
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Confidentiality Covenant/"No Surprises"
The communication between client and counselor is considered confidential except as where required by law, i.e., where there is a threat of serious harm to self or others, such as, but not limited to, child abuse, suicide or homicide.
Only with your consent, you may allow your counselor to share your information and session notes with a third party medical or mental health provider for your treatment and care. You may revoke permission to share at any point in the treatment process. Whatever information that may have been shared to that point will of course, be exempt.

Under Section 2799B-6 of the Public Health Service Act (No Surprises Act), health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services. The cost per service has been disclosed to you prior to booking. Should you have questions or seek further clarification, please let your therapist know. 
By clicking "yes" below, I indicate that I understand my rights as a client, and agree to these terms and conditions. *
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