Email

Mailing Address

Message

Spouse's Name

Will attend sessions with you?

May leave message

Date of Birth

Spouse's Date of Birth

Current Marital Status

Highest Eduacation Completeed

Employer

Occupation

Spouse's Employer

Spouse's Occupation

Church

Is your Christian faith an important resource?

Have you ever seen a mental health professional (psychiatrist, psychologist, or a counselor)?

If yes: Previous Mental Health Professinal/Agency. Where? Dates of Service?

Have you ever been hospitalized for mental health concerns?

If yes: When and Where

List by Household your current family (excluding self) Name, Age, Gender, and relationship to you.

Currently involved in a custody dispute:

If yes please explain.

Primary Care Physician Name and Phone Number

Physical Disability

If yes please explain

Chronic Illness

If yes please explain

Terminal Illness

If yes, please explain

What Medication are you currently taking? Please provide dosage and reason for taking medication.

Please explain any checked Current Family Stressors

History of emtional/behavioral problems

If yes please explain

History of alcohol/drug/substance abuse

If yes please explain

History of family violence

If yes please explain

History of criminal activity

If yes please explain

Briefly describe the problem that has brought you into therapy

How were you referred?

Adult Admission Form