Name ______________________________________ Date_______________
Phone ________________Cell_____________ E-mail_______________________
Address ____________________________________________________________
City ________________________ State ______ Zip ___________ Occupation__________________________________________________________
Business Phone _________________
Name & Address of Company__________________________________________ ___________________________________________________________________
Sex ___ Birth Date ________ Age _____Social Security Number___________
Marital Status: Single __ Going Steady __ Married ___ Separated ___  Divorced ____   Widowed __
Education (last year completed) ____
School Name(s)________________________________________________________ ______________________________________________________________________ 
Other Training (list type & years)____________________________________
Referred here by: ____________________________________________________
Rate your health (check): Very Good_____ Good_____ Average_____
Declining ____.
Weight changes recently: Lost___ Gained ____
Your Physician _____________________________________________________ 
Address _____________________________________________________________
Are you presently taking medication? Yes__  No____.
Have you ever been arrested? Yes___ No____ State circumstances: ______________________________________________________________________
_____________________________________________________________________
Are you willing to sign a release of information form so that your counselor may write for a social, psychiatric, or medical report?
Yes__ No____  
Denominational preference: _____________________________Member______
How often do you attend church? ____________________________________
Church attended in childhood: _________________________________________ 
Baptized?  Yes__ No__
Religious background of spouse (if married) ______________________________
Do you pray to God? Never___ Occasionally___ Often___
Are you saved? Yes__ No__  Not sure what you mean._____
How frequently do you read the Bible?  Never___ Occasionally ____  Often___.
Do you have regular family devotions? Yes___  No___ 
Explain recent changes in your religious life, if any __________________
________________________________________________________________________