Step 1 of 9 11% Personal InformationDate Name First Last AgeDOBGenderMaleFemaleAddress Street Address Address Line 2 City ZIP Code Home PhoneCell PhoneWork PhoneEmail OccupationCounseling ForSelfCoupleChild/TeenReferred By:Marital StatusMarriedSeparatedDivorcedWidowedSingle Religious Background (Check those that apply)I am Uncertain about God, but want to know more Yes No I read the Bible Yes No I have recently faced changes in my spiritual beliefs Yes No Marriage InformationName First Last AgeDOBGenderMaleFemaleAddress Street Address Address Line 2 City ZIP Code Home PhoneCell PhoneWork PhoneEmail OccupationTime you knew spouse before marriage?Any Previous Marital Counseling (if so, explain)Have you ever separated or filed for divorce (if so, explain)Any other Marriages? I currently take medication Yes No What medicationI use alcohol or other drugs Yes No ExplainI have a chronic illness, injury, disability Yes No explainSerious Loss Yes No ExplainPersonal, Business? Yes No ExplainCurrently seeing a counselor? Yes No If so, who? Emotional / Behavioral Problems Drug Abuse Alcohol Abuse Chronic Lying Stealing Violent Behavior Hyperactive Animal Cruelty Assault Others Fire Setting Disobedient Not Trustworthy Hostile / Angry Mood Indecisive Immature Bizarre Behavior Extreme Worry Threats of Self-Injury Frequently Tearful Lack of attachment Acts of Impulse Poor Concentration Break things in Anger Distrustful Acts of Self Injury Easily Distracted Often Sad Frequent Daydreams Repeats Words of Others OtherWhat are you current presenting problems or struggles?List current symptoms & circle level of impact on day-to-day life1.UntitledMildModerateSevere2.UntitledMildModerateSevere3.UntitledMildModerateSevere4.UntitledMildModerateSeverePeople Living in HouseholdName, Relationship, Age HistoryEarly Childhood Losses (before age of 10)Describe any serious hospitalization accidents EmploymentSelect from following choices Employed & Satisfied Employed & Dissatisfied Unemployed Coworker Conflicts Unstable Work History Supervisor Conflicts Disabled Financial SituationSelect from the following choices No Current Financial Problems Large Indebtedness Impulsive Spending Poverty or Below Poverty Income Relationship Conflicts Over Finances Legal HistorySelect from the following choices No Legal Problems Currently on Parole Arrest (Substance) Court Ordered Treatment Jail / Prison (Time Served) Counseling Appointments: Call 253.432.4553 at least 24 hours before your appointment if you are unable to keep it. Cancellations without proper notification may forfeit continued counseling.