Counseling Request

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Counseling

Counseling Request

To allow us to be efficient at helping, when you come to the office, we will ask you to fill out some important documents that will provide us with the information we need to best counsel with you.

Information from this form goes directly to the GraceWorks Ministry and allows your counselor to have the information so he or she can be prepared to provide you the best possible service.

YOU WILL NEED TO MAKE AN APPOINTMENT WITH US AFTER YOU FILL OUT THE FORM. The contact information will be available upon successful completion of this form.

Client/Parent Name
Date of Birth
Age
Address
City
ZIP
Email
Home Telephone
Work/Other Telephone
Occupation
Employer
Education Level
Church You Attend
Church Member?	Yes No
Marital Status	Single Married Divorced Separated
Years Married
Years Divorced
Months Separated
Number Children
Names & Ages
Spouse
Spouse Date of Birth
Spouse Age
Spouse Occupation
Spouse Employer
Spouse Education Level
Spouse Work Telephone
Minor Client?
Minor Name
Minor Date of Birth
Minor Age
Gender	M F
School
Grade
Current Medications
Recent Health Problems
Other Counselor(s) Seen
Reason for Appointment
Symptoms Started
Referred By
Emergency Contact Name
Emergency Contact Telephone