WELCOME TO FAITHFUL LOVE MISSIONARY CHRISTIAN COUNSELING CENTER WOMEN INFORMATION FORM Step 1 of 4 25% Faithful Love Missionary Christian Counseling Center Client Intake InformationYour Name* First Name: Last Name: Date form filled out: MM slash DD slash YYYY Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork Phone:Cell Phone:May Faithful Love Missionary Christian Counseling Center contact you via: Home Phone Number: Yes No Work Phone: Yes No Cell Phone: Yes No May Faithful Love Missionary Christian Counseling Center leave a message on: Home Phone Number: Yes No Work Phone: Yes No Cell Phone: Yes No Email* Clients Nick NameD.O.BAgeGender:Place of Birth:Please tell Faithful Love Missionary Christian Counseling Center yourMarital Status S M D W If married, how long?Spouse’s NameorParent/Guardian Name(s)Gender: Male Female Phone #2:Email Your Employer:Position:Religion were you lived as a child:Currently:Referral Source:Faithful Love Missionary Christian Counseling Center would like to thank him or her for the referral. May Faithful Love Missionary Christian Counseling Center have permission to send a thank you note? Male Female Person to contact in case of emergency:Telephone:Last Grade levelEmergency Contact:Household members:Signature Please indicate what major stressors and/or changes have you experienced in the past 12 months: Serious Illness Death of a friend/family member Divorce/Separation Major family illness Relationship change School/Employment change Financial instability Obsessive/Compulsive behavior Sexual issues Sleep Eating/Appetite Exercise Weight Concentration Panic attacks Social isolation Physical abuse Sexual abuse Emotional abuse Suicide attempt Self harm Violent behaviors Legal problems Suicidal thoughts Other Concerns: if yes, please explain: please explainRate your strengths and protective factors: Secure Housing Present Absent Secure Employment Present Absent Unknown Social Support Present Absent Unknown Perceived Family Support Present Absent Unknown Perceived Responsible for Others (family, close friends, etc) Present Absent Unknown Coping Skills Present Absent Unknown Faith/Spirituality Present Absent Unknown Insight From Others Present Absent Unknown Problem Solving Abilities Present Absent Unknown Ability to Adapt/Change Present Absent Unknown Sense of Purpose or Meaning In Life Present Absent Unknown Additional Strengths: Present Absent Unknown Family Information Is there a biological family history of: Depression Suicide attempts Anxiety Eating Disorders Mental Illness Emotional abuse Physical abuse Sexual abuse Faithful Chronic illness: if yes, please explain Chronic illness: please explainSignature Medical Information Primary physician:Phone:Date of last exam:Major or Chronic Illness/Injuries:Operations:Current Medications Dosage Frequency Effectiveness Prescribing PhysicianHave you ever been prescribed medication for psychiatric or emotional problems? Yes No When Prescribing Doctor Prescription Reason for Rx EffectsHave you ever been hospitalized for a psychiatric or emotional health reason? (inpatient/outpatient) Yes No If yes, please describe the following: When Hospital Reason ResultsSubstance Use Information Tobacco/Vaping Do you smoke? Yes No If no, did you smoke in the past? Yes No If yes: How many times a dayBegan at what age?If you no longer smoke, when did you quit?Do you consume or abuse substance? Yes No If so, how much? 1x/month 3x/month 1x/week daily other Check all that apply: beer wine hard liquor Drugs (including marijuana) Do you use any street drugs and/or misuse prescription drugs? Yes No Name of DrugFrequency of UseHave you ever been in a drug treatment program? Yes No No If yes, please specify: InpatientOutpatient WhenHow long:Outcome:Is there anything else your mental health provider should know prior to beginning counseling?What would you like to be different in your life when therapy concludes?How were you referred to counseling? PEOPLE CURRENTLY IN HOUSEHOLD INCLUDING YOURSELF Name Relationship to Client Age Gender Educational Level Occupation 1 You Self X X 2 34 5 6 Continue on back if necessary Any children not living in household?What is the major concern that led you to seek help?What other concerns do you have?Please describe any “yes” answers to the questions below.Are you consistently down or depressed mood most of the day or nearly every day? Yes No Do you have a diminished level of interest in most or all activities? Yes No Change in appetite? Yes No Fatigue or loss of energy? Yes No Change in sleep pattern? Yes No Feelings of worthlessness or excessive guilt? Yes No Difficulty thinking or concentrating? Yes No Thoughts of death or suicide (or any attempts)? Yes No Increased irritability or violent behavior? Yes No Attacks of hyperventilation, palpitations or intense fear? Yes No Do you have any phobias or unusual fears? Yes No Ever experience a “natural high” in absence of substance abuse (with increased energy, mood, decreased need for sleep, talkativeness, etc.)? Yes No HeightWeightLowest WeightAny history of food binging?Do you have any history of excessive drug use? (Briefly describe)Have you experienced any traumatic events in the past or currently? (Briefly describe)Have you ever been in therapy? (Give name of therapist, dates and describe concerns that were discussed)Any major medical problems (i.e. thyroid, diabetes, asthma, etc.)?Any prior hospitalizations (give date, reason, type of treatment or treatment recovery received in the past or currently)?Are you currently under the care of a physician and/or psychiatrist? If so, whom? And for how long?List all medications you are currently or have recently taken. Give Faithful Love Missionary Christian Counseling Center the names, dosage and duration of usage.Research has shown that heredity plays a role in many disorders. Please take time to tell Faithful Love Missionary Christian Counseling Center of your various blood related relatives. Indicate any who have had similar symptoms as your self. Also, note if any had problems (when treatment recovery was received) with the following: anxiety, depression, manic depression, changes in behavior or mood, eating disorders, phobias, drug dependency, etc.) Please note and tell Faithful Love Missionary Christian Counseling Center of any other emotional or medical problems.RELATIVE PROBLEMIs there anything else that would be helpful for Faithful Love Missionary to know?In your own words, what are three goals you would like to work towards during therapy?I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes regarding the above information. Please sign below indicating you have provided the most recent and official legal document concerning custody/visitation and parental rights: Honesty Declaration: I,attest that the answers provided throughout this client information form have been answered truthfully and completely to the best of my recall. I attest that I have not deliberately or intentionally misrepresented my medical, social or psychological history in any way with my responses. SignatureDate MM slash DD slash YYYY
