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January 2012 Newsletter

______________________

Stop making excuses and take a stand.

If you would like to support our ministry financially, you can do so by making a donation using your Paypal account or credit card.

PERSONAL INFORMATION
Full Name:
Email Address:
Address:

City:	State: Zip:
Phone:
Occupation:
Gender:	Male Female
Birth Date:	Age:
Marital Status:
Were you brought up by anyone other than your own parents? Yes No
If yes, describe briefly:

Date you met:

Give a brief statement of circumstances of meeting and dating:

Are you planning to marry?	Yes No
Date of wedding:

COMPLETE IF YOU ARE CURRENTLY OR HAVE BEEN MARRIED
Length of steady dating with spouse:
Length of engagement:
Date of Marriage:
Ages at time of marriage: Husband:	Wife:
Briefly describe your relationship:

Spouse's name:
Is your spouse willing to come to counseling?	Yes No Not sure
Have you ever been separated?	Yes No
If yes, when? From to
Has either of you ever filed for divorce?	Yes No
If yes, when? Who filed?
Has either of you been married before?	Yes No
If yes, describe briefly:

SPIRITUAL INFORMATION
What church do you currently attend?
Address: Member? Yes No
Church attendance per month:
Have you been baptized?	Yes No When?
Do you consider yourself "spiritual"?	Yes No Uncertain
Are you interested in spiritual matters?	Yes No Uncertain
Do you believe in God?	Yes No Uncertain
Do you pray to God?	Often Occasionally Never
Are you a Christian?	Yes No Uncertain
If yes, when did you become a Christian?
If you have received Jesus Christ as your personal Savior, what changes took place in your life as a result?

How much do you read the Bible?	Often Occasionally Never
Do you have personal devotions?	Often Occasionally Never
Describe your personal devotions:

Do you have family devotions?	Often Occasionally Never
Describe your family devotions:

Explain any recent changes in your spiritual life:

MEDICAL INFORMATION
Rate your physical health: Very Good Good Average Declining
Date of your last medical examination:
Your physician:
Physician address:
Are you taking medications currently? Yes No
If yes, please list below:

Please describe any current medical condition or history pertinent to problem:

Have you received any therapy, psychotherapy, counseling, or other treatment in the past? Yes No
If yes, when? with whom?
Would you sign a release of information form so your counselor may have access to psychiatric, medical or other pertinent records? Yes No

EMOTIONAL INFORMATION
Please check any symptoms that you have had in the last six months:
Change in apetite	Problems concentrating
Difficulty sleeping	Low motivation
Sleeping too much	Isolating from others
Fatigue / low energy	Frequent anger
Low self-esteem	Depressed mood / sadness
Tearful / crying spells	Anxiety / fear
Hopelessness	Panic
Shame	Other
If other:

Please check any of the following that best describe you now:
Acitve	Ambitious	Self-confident	Shy	Hardworking
Persistant	Nervous	Impatient	Impulsive	Moody
Kindly	Excitable	Imaginative	Calm	Serious
Introvert	Likable	Easy-going	Extrovert	Leader
Quiet	Lonely	Good-natured	Sensitive	Self-conscious
Fearful	Bitter	Rebellious	Submissive	Other
If other:

Referred by:

Please describe concerns that brought you here today:

What have you done in attempting to resolve these problems?

What are your expectations in coming for counseling?

What circumstances led to your coming here at this point in time?

Is there any other information we should know?