Type of Counseling:
*
Name
*
First Name
Last Name
Gender
Date of Birth
*
MM
DD
YYYY
Age:
Email:
*
What is your preferred method of communication?
(Check all that apply)
Cell #:
*
(###)
###
####
Secondary Phone #:
(###)
###
####
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Counseling needed for:
(check all that apply)
Marital Status
*
Spouse (if applicable):
First Name
Last Name
Spouse's Age:
Date Married:
MM
DD
YYYY
Place Married:
If you have ever separated please provide dates and circumstances:
Rate Your Marriage:
What might make it better?
Children from present marriag: (Name, Son/Daughter, Age, Where Live, Marital Status, Occupation)
Your Previous Marriages (or Relationships that Produced Children) (if applicable): Name of Spouse/Partner Dates Children (Names and Ages)
Has your spouse been previously married?
Number of times?
Children names and ages:
Education Level:
Some High School
High School
College
Post Graduate
School/Institution attended:
Occupation:
Company Name:
City and State:
Years there:
Work Phone:
(###)
###
####
Does your present work satisfy you? Explain
What other job positions have you held in the past?
Father:
First Name
Last Name
Father (Age, Where Live, Marital Status, Occupation)
Mother:
First Name
Last Name
Mother (Age, Where Live, Marital Status, Occupation)
Guardian:
First Name
Last Name
Relation to you and dates:
Brothers/Sisters: (List in order from oldest to youngest; include yourself in that order): Name Bro/Sis/Step, Age, Where Live, Marital Status, Occupation
Family “Climate”: Describe your home life during your childhood and teen years:
Indicate any problems you experienced as a child or teen:
Other:
Psychological Problems: Have you, or any parent or brother or sister, been hospitalized or received professional help for psychological problems? Specify person, dates, and problem:
Past Denominational Background:
Present Denominational Background:
Preferred Denominational Background:
Church Presently Attending:
Church Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you a member?
Average times attended per month:
Pastor:
First Name
Last Name
Pastor Phone:
(###)
###
####
May we contact?
Do you believe in God?
Do you consider yourself "saved"?
How frequently do you pray?
How frequently do you read the Bible?
What is your view of the Bible?
Describe your view of God:
Describe what you think His view of you is:
Do you have a personal relationship with God and if so, what effect does this relationship make in your daily life?
Why do you desire Christ-centered, biblical counseling?
Explain any recent changes in your religious life:
Rate your health:
*
Recent problems:
*
Date of last medical exam:
*
MM
DD
YYYY
Physician Name:
*
First Name
Last Name
Physician Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
List any prescription medications you take: (Medication, Treatment for, When began, Daily dosage, Prescribing Physician)
List over-the- counter medications you currently take (diet pills, laxatives, birth control pills, cold and allergy medicines, aspirin, etc.):
Average daily caffeine consumption? (coffee, tea, chocolate, stimulants, caffeinated soft drinks, etc.)
How often do you drink alcoholic beverages?
How often do you struggle with the use of an illegal drug(s) and/or a legal substance(s)?
Have you ever received treatment for substance abuse or been through a recovery program?
If yes, please describe when and where you received treatment:
Average hours of sleep:
Is it restful?
Firm Name:
Attorney Name:
First Name
Last Name
Attorney Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Has a legal action been filed or is one likely to be filed in this situation?
Date of Action:
MM
DD
YYYY
Describe Action:
Other information that might be helpful for us to know about you:
Briefly state in your own words the problem(s) or conflict(s) you are facing:
*
For how long have you been facing these problems?
*
What have you done so far about these problems?
How might you like your counselor to try to help you?
What issues or questions do you want to have resolved or answered?
As you see yourself, what kind of person are you? How might you describe yourself?
List any behaviors, thinking, or feelings that you struggle with and would like to change. How have they impacted your life?
List any other information about you or the problems that might be helpful for us to know:
In what specific ways do you think God might want you to change (be honest), and might want your spouse and/or your other family members to change (be tentative)?
Possible changes YOU need to make:
Possible changes OTHERS need to make: (include name and relationship)
Availability for Individual Counseling:
Please check all that apply. (All marriage counseling is only offered in the evenings.)
Do you give WSM permission to contact you via Phone, Text and/or Email?:
How did you hear about Watershed Ministries and who referred you?