Counseling Request Personal InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail* Age* GenderSelect oneMaleFemale Family InformationMarital StatusSelect oneSingleMarriedSeparatedDivorcedWidowedSpouse's Name First Last Date Married MM slash DD slash YYYY Have you been married previously?Select oneYesNoDo you have children?Select oneYesNoNames and ages of childrenHave there been any deaths in the family in the past two years?Select oneYesNo Employment InformationAre you employed?Select oneYesNoWhere? How long have you been at this position? Is your spouse employed?Select oneYesNoWhere? How long has he/she been at this position? Spiritual InformationDo you believe in God?Select oneYesNoUncertainDo you pray to God?Select oneRegularlyOccasionallyNeverDo you read the Bible?Select oneRegularlyOccasionallyNeverIs Calvary Chapel your home church?Select oneYesNoHow many times a month do you attend church? Have you received Jesus Christ as your Savior?Select oneYesNoUncertainWhen? Have you been baptized in water since you received Christ?Select oneYesNoHave you been baptized in the Holy Spirit?Select oneYesNoUncertainWhen? Have you been involved in any cults or occult practices?Select oneYesNoPlease explain.Health InformationRate your health.Select oneVery GoodGoodAveragePoorPlease list any significant illnesses, injuries or handicaps.Please list any medication(s) you are currently takingHave you had a medical exam in the last year?Select oneYesNoHave you had any professional counseling before?Select oneYesNoHas your weight changed significantly in the past year?Select oneYesNoHave you ever or do you now use alcohol or drugs?Select oneYesNo Briefly answer the following questionsWhat are your main problems or areas of concern?What have you done to resolve this problem?Please describe what person(s), situation(s) or activities seem to trigger this problem or make it worseIs there any other information that we should know?Select oneYesNoPlease explain.EmailThis field is for validation purposes and should be left unchanged. 97175Δ
