INFORMATION REQUESTED IS FOR THE SOLE PURPOSE OF SERVING YOU

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PLEASE ENTER FULL NAME                                                                          DATE OF BIRTH                         SSAN

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PLEASE GIVE YOUR FULL MAILING ADDRESS ON THIS LINE INCLUDING CITY AND ZIP CODE

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HOME PHONE                                                     OFFICE/WORK PHONE                               EMERGENCY PHONE

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Who recommended you make an appointment with me? Write name above. If it was a pastor, doctor, other counselor, or judge do you want a consult performed with them? If so check yes here ______ Release forms will have to be initiated for this to occur.

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NAME OF SPOUSE OR NEAREST RELATIVE // GIVE THEIR PHONE NUMBER IF DIFFERENT FROM YOURS

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NAME OF PERSONAL PHYSICIAN                                                                     PHONE NUMBER OR TOWN         LAST SEEN

Would this be the person you would see for medical services if it was determined to be needed? _______

Are you currently under a doctorís care? Yes ___ No ___ If yes, describe what you are being treated for.

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If the physician currently treating you is a specialist or someone other than the one listed above, write in their name, phone number or town and reason for treatment on the lines below.

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Write in all medicines, both prescription and non-prescription, you are currently taking. If this changes while in counseling you are responsible to notify your counselor on the next visit after the change.

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Write in all herbal remedies, vitamin and mineral supplements, you are currently taking. If this changes while you are in counseling notify your counselor on the next visit after the change.

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When was your last medical exam and what was the outcome?

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Do you have any chronic or acute illnesses, injury, or disability? If so, explain.

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Have you ever used or been treated for addictions to controlled substances or alcohol? If so describe.

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How would you describe your health? Excellent ___ Good ___ Fair ___ Poor ___

 THE FOLLOWING QUESTIONS PERTAIN TO YOUR MARITAL STATUS:

Check the following that apply to you. If you have been divorced or widowed write in number of times.

MARRIED ___    DIVORCED ___    SEPARATED ___    WIDOWED ___    ENGAGED ___   SINGLE ___

If you are currently married, would you describe your marital life as happy ___ unhappy ___  unsure ___

If marital issues are part of your reason for seeing me, please answer the following;

Do you have a history of marital abuse ___ sexual abuse ___ broken relationships ___

Have you previously lived with someone without benefit of marriage ___ How many times ___

Are you living with someone without benefit of marriage now ___      How long in years ___ & months ___

What would you like to tell me about your marital life at this point? Write below.

 

THE FOLLOWING QUESTIONS RELATE TO YOUR FAMILY AND GRIEF HISTORY.

Please either check for yes or fill in appropriate numbers/dates/etceteras as the question requires.

 Please write in your parents' names.        Mother _____________________________ maiden _________

                                                                       Father ______________________________________________

Is your mother still living? ___ If not, has she recently died? ___ How long has this been? _____ age ___

Is your father still living?   ___ If not, has he recently died?   ___ How long has this been? _____ age ___

Do you have brother or sisters? ___ If so how many brothers ___ and sisters ___

Where are you in the birth order? Eldest ___ Youngest ___ Middle ___ Other ______________________

Have you lost a sibling in the last 5 years to death or disappearance? ___

Did you live with other family groups growing up? ___ How many? ___ If so, ask for Extended Residences Survey

Do you maintain close contact with all ___ some ___ of your family members? If some of your living family is not communicated with for cause, please explain below.

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Is there any history of sexual, verbal, emotional, or physical abuse in your family? ___ If you checked yes please explain below. If you are experiencing any of these types of abuse within your marriage ask your counselor for the form on marital abuse.

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Briefly describe yourself as a person. ______________________________________________________

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Describe in your own words the help you would like to receive from this ministry.

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Check the following categories of problems that you need help in. They are arranged in types for your convenience.

Depression ___  Anger ___  Emotional problems ___  Stress ___  Anxiety ___  Panic ___   Other ______

Addictions   ___  Drugs ___  Alcohol  ___ Sexual ___  Food  ___  Compulsive behavior ___

                           Gambling  ___  Lying ___  Stealing ___  Television  ___ Pornography ___  Other _____

Marital ___          Relationships ___  Communications  ___  Tenderness  ___  Sexual  ___    Other _____

Thoughts ___      Repetitive  ___      Suicidal  ___  Hearing Voices  ___  Negative thinking ___

Losses ___         Marital-divorce/separation ___ Death ___  Job/Career ___  Physical ___    Other _____

Parenting issues  ____ Child development ___ disobedience ___  Family foundations ___    Other _____

                                      Lack of parental agreement in child rearing  ___

Self Esteem Issues ___ Low self worth ___ outrageous behaviors  ___ rejection of others ___

                                      fear of rejection by others  ___  Abusive to others ___ Abusive to self ___

Occult/demonic  ____   If you have been involved in occultic activity including astrology, fortune telling,

                                     Ouija boards, membership in groups or organizations you may be asked to

                                     complete an additional questionnaire. 

Note: This list is not exhaustive and counseling is performed in other areas. The above are some of the most common. If you have others, please write them below in one or two word each to describe the area of need.

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Your educational level and ability to comprehend affects the types of counseling resources we can call on in order to help you. Write in below all the educational experiences you have had. If you ceased your education prior to reaching your educational goals or achieving a diploma, please explain why as well.

 Did not go beyond grade 12? The grade you completed ____ , the number of years you attended ___ ,

 Have a GED check ___ High School diploma ____. Is it Academic/College Prep ___ General ___ .

 Technical School ___ Write in course completed or time attended _______________________________

 College? Years attended ___ Highest degree earned _________________________________________

 Were you ever classified as a discipline problem ___ expelled ___ suspended ___ ISS ___ experienced relationship problems with  teachers ___ fellow students ___ frequent fights ___ other ___  please explain

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 How would you describe your reading comprehension?            Excellent ___ Good ___ Fair ___ Poor ___

 THE FOLLOWING IS AN INQUIRY INTO YOUR COUNSELING TREATMENT HISTORY

Your past experience with counselors and history of counseling can have a decided impact on how you respond to counseling in these present circumstances. In order to serve you we need to understand what experiences of counseling, psychology, and psychiatry practitioners you bring into counseling with you.

 Have you ever been treated by a counselor ___  psychologist ___  psychiatrist ___ ?  How many? _____

 Did the person claim to be a Christian practitioner? (more than 1 write in numbers each)  Yes ___ No ___

 Did you seek counseling for the same ___ or another ___ problem than the one currently bothering you?

If you sought counseling for another problem, even if it was related to your current one, briefly describe it

(You may attach additional paper if needed. If you have seen several people, please separate treatments in order of person seen)

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 Briefly describe your experience of counseling.

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You may attach additional paper if needed.

Do you understand that Christian Counseling is radically different from counseling performed by secular practitioners? Yes ___ No ____ Do you understand that not all people who claim to be practicing Christian Counseling are in fact doing so? Yes ___ No ___ Many people do not know this, and if you are unclear ask your counselor to discuss this with you as a prelude to beginning your new experience.

 Would you be willing to sign a release for your previous counselor to share their records?  Yes __   No __

 If you have something you would like to communicate at this point, please write it in below.

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 CHURCH ATTENDANCE CONSISTENT WITH AN INDIVIDUALíS WORK SCHEDULE IS A MANDATORY PART OF THE CHRISTIAN COUNSELING EXPERIENCE. IT IS NOT AN OPTION.

Christian Counseling assesses a person in six areas. One of the most important of these is the Spiritual. For that reason, spiritual assessment is performed as an initial part of the application process. Not all who come to Christian Counselors are Christians. And even Christians live on different spiritual levels.

 When we use the term Christian, we do not mean someone who has been born into a Christian home or who has attended church all their life. We mean someone who has had a personal experience of the Lord Jesus Christ in their life. Are you a Christian? Yes ___ No ___

 If you answered yes to the above question, you should be able to point to a time when you received the Lord Jesus Christ as your personal Savior. Can you tell us about how long ago that was for you? ______

 Can you tell us where you were when you asked Jesus Christ to come into your life?        Yes ___ No ___

 here? _____________________________________________________________________________

Describe what happened (You may attach additional paper if needed)

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 What has happened in your life since you came to the Lord Jesus Christ and asked Him in?

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 Do you pray daily? How often do you pray? _________________________________________________

Do you have daily Bible reading? Yes ___ No ___ Do you have a Bible reading plan ___ or read randomly ___ ? Do you only read your Bible when you come to church? Yes ___ No ___

 Do you currently attend church? Yes ___ No ___ If so, how often? _______________________________

 What is the name of your church? ________________________________________________________

 Who is the pastor? ____________________________________________________________________

 Do you have any jobs/responsibilities in your church? Yes ___ No ___ I used to have ___

 What are/were they? __________________________________________________________________

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Is your mate interested ___ uncaring ___ in spiritual things? Do you do them together?  Yes ___ No ___

How would you describe the state of your spiritual health in your own words?

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            Jonsquill Ministries

P. O. Box 752

Buchanan, Georgia 30113

171001-1