COUNSELLING INTAKE FORM
Copyright 2009 Emerge Christian Counselling.
Legal disclaimer:
This service is not intended for individuals who are planning to harm themselves or others. If this is the case, please contact the relevant crisis hotline in your area. ions through this website. You agree that the information on this form may be published at a later date although no real names would be used. I agree to forever release, discharge and indemnify George Sukhdeo and Emerge Christian Counselling Centre from all actions, suits, claims arising from receiving counselling on this site.
If you accept the terms of the above disclaimer, please check the box below and then press submit.
First Name
Full Address
Age
City
Home Phone
Office Phone
E-mail
Cell Phone:
Physical History: Please be accurate, medical records may need to be disclosed at some point in necessary
General Health
Are you under a doctors care?
If yes, name of doctor
Reason for doctors care
Are you treated with medication?
If yes, describe
Reason for medication
Date of last medical examination
Have you ever been hospitalized for physical illness?
If yes, please describe
Any recurrent or chronic condition?
Have you ever been hospitalized for mental illness?
If yes, please describe
Any recent major illness or surgery ?
If yes, please describe
If yes, please describe
Do you smoke cigatettes ?
Do you use drugs?
If yes, describe
Do you use alcholic drinks ?
B. PARTNER'S INFORMATION (IF MARRIED):
Have you had any previous therapt/counselling
If yes, what for?
By who?
How many sessions ?
A. PERSONAL INFORMATION
Surname.
Occupation
First Name
Surname
Age
Occupation
Full Address
C. RELATIONAL STATUS:
Single
Married
Date of marriage
Separated
Date of separation
Divorce
Date of Divorce
Common Law
Date Started
Remarried
Date
Engaged
Date
Wedding Date
Relationships before marriage
D. SPIRITUAL BACKGROUND
Catholic
Protestant
Other
Denomination
Pastor's Name
Catholic
Protestant
Name Of Church (if any)
Attendance how often ?
How many brothers in your family
How many sisters in your family
Results
E. NUCLEAR FAMILY : ( Your Present family)
1.
2.
3.
NAMES OF CHILDREN
4
AGE
NAMES OF CHILDREN
AGES
J. PRESENTING CONCERNS: (CHALLENGES THAT YOU NEED HELP IN)
1.
2.
3.
4.
5.
6.
K. PERSONAL AGREEMENTS
CLIENT'S:
I understand that the counselling process involves certain "homework exercises" such as reading, praying, changing and adding new behaviors, and otherwise acting in the interest of a wholesome and better way of living in my own best interert and as well in ther interest of my loved ones. I understand that I am entirely responsible for my own actions and will always make my own final decisions considerig the guidance I receive.
I also understand that much of the work done will be to rsolve issues and will depend on my honesty, and willingness to sacrifically do the things I need to do to move forward even if it is humbling and challenging.
I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent, unless I am violating the codes of abuse, and harm to myself and others.
I understand that I will have to pay $ 85.00 for any appointment not cancelled 24 hours before the set session of counselling.
Signature__________________________________________ Date_____/_____/_____
L. COUNSELLOR/THERAPIST:
Our greatest joy and fullment comes from seeing you emerge into a wholesome, peaceful and fruitful life. We will be committed to in all my endeavours in serving you with the best of our ability and potential. We will esteem you as in the image of God as He has created you to be. You will have our respect at all times. We will use the best of our training and experience and will seek Godly wisdom and guidance in helping to resolvie the challenges that will be before us. With compassion and empathy we will work together with you and those who may be involved.
Signature:___________________________________________ Date;_____/_____/_____.
Please click the button to right to submit the infomation above. Thank you
