Client Intake Form Date* Date Format: MM slash DD slash YYYY Referred by:Name* First Last Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Home)Phone(Work)Phone(Cell)Employer*Position:*Gender*MaleFemaleAge*Date of Birth Date Format: MM slash DD slash YYYY Relationship Status:*SingleMarriedSeparatedDivorcedWidowedReligious 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 NameAge I am seeking counseling and discipleship services for:* Individual Couple Family Group When?*Have you received counseling previously?*NoYesName 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.
