Name *

First

Last

Date *

Email *

Phone

Address *

Address Line 1

City

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Zip Code

Age

Birthdate *

Gender *

• Male
• Female

Marital Status *

• Single
• Married
• Seperated
• Divorced

Current Living Situation:

What is your religious affiliation?

Are you a member of World Harvest Church?

• Yes
• No

If no, How often do you attend?

Have you taken a membership class?

• Yes
• No

Where do you Serve?

Are you in a Ministry Group?

• Yes
• No

Have you had any previous or present counseling? *

• Yes
• No

If yes, a brief explanation:

Are you currently in the care of a Doctor?

• Yes
• No

If yes, give reason:

Do you take any medications?

• Yes
• No

If yes, name the medication:

Have you ever been in a mental or psychiatric facility?

• Yes
• No

Why are you requesting counseling today?

What do you wish to gain from this counseling session?

Signature *

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