Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name:Date of Birth:Address:Contact Info. Emergency Contact:Preferred Method of CommunicationPhoneEmailTextWhat is your highest level of education completed?What type of school did you attend? PublicPrivateChristianHomeschoolWere there any challenges or highlights in your educational journey?What is your current occupation?How do you feel about your work environment?Are you currently satisfied with your career path?Have you experienced any work-related stress or trauma?Relationship StatusMarriedSingleDatingDivorcedWidowedIf married, how long have you been married?Describe your family of origin (parents, siblings, household structure).List names and agesWere there any significant events in your childhood that shaped your worldview? How was discipline handled in your home?What traditions or values were emphasized in your upbringing?Do you have children? If so, how many?List birthdate and names. Are there any challenges you are facing as a mother? Do you feel supported in your role as a mother? What are your core values?Are there any spiritual practices that you engage in regularly? (prayer, bible study, fasting)?Do you feel any conflict between your beliefs and your current life circumstances?Have you ever been diagnosed with a mental health condition (e.g. depression, anxiety, PTSD, bipolor disorder)? If yes, please specify:Are you currently experiencing any of the following? (Check all that apply)AnxietyDepressionMood SwingsPanic AttacksSleep DisturbancesDifficulty ConcentratingFeeling HopelessThoughts of Self-Harm or SuicideOtherHave you ever received counseling, therapy, or psychiatric care before? If yes, for what reason?Are you currently taking any medications for mental or emotional health? If yes, please list:Are there any past traumas or significant life events that you believe are affecting your mental health today? How do you typically cope with stress or emotional pain?What prompted you to seek Christian counseling at this time?What are your primary goals for counseling?Are there specific issues you'd like to address? (e.g. anxiety, grief, relationship struggles)?What do you hope to gain spiritually, emotionally, and relationally? Submit
