Intake Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth date *

MM

DD

YYYY

Sex *

Male

Female

Relationship status *

Single

Married

Remarried

Separated

Divorced

Widowed

Please check any of the following physical problems that would apply to you

Allergies

Amnesia

Anorexia

Blackouts

Bowel/bladder

Brain Tumor

Bulimia

Cancer

Changes in Consciousness

Changes in Sexual Drive

Constant Hunger

Déjà vu

Dizziness

Episodic Disorientation

Fatigue

Food Cravings

Hallucinations

Head Stroke

Headaches

Heart Problems

Heat/Cold Sensitivity

High Blood Pressure

Impotence

Incoordination

Injury/Concussion

Kidney Problems

Liver Problems

Lung Problems

Memory Problems

Menstrual Irregularities

Multiple Sclerosis

Nausea/Vomiting

Parkinson’s Disease

Personality Change

Physical Change

Pneumonia

Problems Walking

Rashes

Seizures

Sensory Distortion

Speech Problems

Stiff Neck

Unusual Hair Loss

Visual Problems

Weakness

Weight Change

Rate your health *

Very Good

Good

Average

Declining

Other

Have you recently suffered loss from serious social, business, or other reversals? *

Yes

No

Have you recently suffered loss of someone who was close to you? *

Yes

No

Have you gone to them for help? *

Yes

No

Church attendance per month *

0

1

2

3

4

5

6

7

8

9

10+

Do you consider yourself a religious person? *

Yes

No

Uncertain

Do you believe in God? *

Yes

No

Uncertain

Do you pray to God? *

Never

Occasionally

Often

Are you saved? *

Yes

No

Not sure what you mean

How much do you read the Bible? *

Never

Occasionally

Often

Do you have regular family devotions? *

Yes

No

Please check any of the following words which best describe you now *

Abusive

Active

Ambitious

Angry

Calm

Cruel

Easy-going

Embarrassing

Ethical

Excitable

Extrovert

Godly

Good-natured

Hard-boiled

Hardworking

Hypocritical

Imaginative

Impatient

Impulsive

Introvert

Irresponsible

Leader

Likable

Lonely

Moody

Nervous

Often-blue

Persistent

Proud

Quiet

Self-confident

Self-conscious

Sensitive

Serious

Shy

Strict

Submissive

Uneducated

Unreasonable

Have you ever felt people watching you? *

Yes

No

Do people’s faces ever seem distorted? *

Yes

No

Do colors ever seem too bright? *

Yes

No

Are you sometimes unable to judge distance? *

Yes

No

Have you ever had hallucinations? *

Yes

No

Are you afraid of being in a car? *

Yes

No

Is your hearing exceptionally good? *

Yes

No

Do you have problems sleeping? *

Yes

No

Indicate which might have applied during your childhood and/or adolescence

School problems

Social problems

Family problems

Legal problems

Medical problems

Sexual abuse

Drug/alcohol abuse problems

Spouse's name

First Name

Last Name

Spouse's phone

(###)

###

####

Spouse's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Spouse’s dirth date

MM

DD

YYYY

Is your spouse willing to come for counseling?

Yes

No

Uncertain

Date of marriage

MM

DD

YYYY