Counseling Intake Form

Personal Data Inventory

Marriage Information
Name of spouse

First NameLast Name
Spouse's Phone

Area CodePhone Number
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Occupation
Spouse's Place of Business
Spouse's Business Phone

Area CodePhone Number
Spouse's Age
Spouse's Education (years)
Is your spouse willing to come in for counseling?

YesNo
Have you ever been separated?

YesNo
Has either of you ever filed for divorce?

YesNo
Date of this marriage
Your age when married
Your spouse's age when married
How long did you know your spouse before marriage?
Length of steady dating with spouse
Is this your first marriage?

YesNo

Basic Information Page
What is the main problem, as you see it? What brings you here?*
What have you done about it?*
What can we do? What are your expectations in coming here?*
As you see yourself, what kind of person are you? Describe yourself.*
Is there any other information we should know?*
What is your availability? Days of the week and timeframes.
We do the majority of our counseling on Sunday evenings at 4:00, 5:00, 6:00, and 7:00. A handful of our counselors are available during the week on Monday's, Tuesday's, Wednesday's, and Thursday's. Please provide specific day(s) or time(s) that works best for you to meet with a counselor in the Date/Time Preference field below.
Date/Time Preference:*
Please indicate if there is a specific counselor you would like to see.
We will try our best to accommodate your request based on the counselors scheduling availability.
Are you a member of Harvest New Beginnings Church?*

YesNo
Please note that you'll sign the Agreement portion of this document when you come in for your first counseling session.
Please note that you'll sign the Agreement portion of this document when you come in for your first counseling session.

Should be Empty: