Client Intake Form - Solid Rock Biblical Counseling

Date*

Referred by:

Name*

First Last

Email*

Address*

Street Address City State ZIP Code

Phone(Home)

Phone(Work)

Phone(Cell)

Employer*

Position:*

Gender*

Male
Female

Age*

Date of Birth

Relationship Status:*

Religious Preference:*

Church you belong to:

Name and telephone number of significant other (or person to contact in case of emergency).*

Relationship to you*

Phone*

Children’s names and ages:

Child's Name	Age

I am seeking counseling and discipleship services for:*

Individual
Couple
Family
Group

When?*

Have you received counseling previously?*

No
Yes

Name of your counselor:*

State in your own words why you are seeking counseling at this time:*

We do not give medical advice or recommendations about medications.
We are trained to use the Scriptures to address difficulties for those who seek help.