New Clients for Rick Pierce

HeartStrong Ministry

New Client Secure Intake Form
Name *
Address *
City, State, Zip *
Date of Birth *
What is the best phone number to reach you? *
May we have permission to call you and leave a message regarding your counseling? *

Yes No
What is the best email address to reach you? *
May we have permission to email you information regarding your counseling? *

Yes No
Who referred you to see Rick? *
What is your occupation? *
Marital Status *
If married, when were you married?
If you have been married before, please provide dates for marriage(s) & reason with the date of the end of the marriage:
If you have children, please list their sex and ages.
Yes, I am very involved at my church.

Yes, I am very involved at my church. Yes, I attend each week. Yes, but I only attend on ocassion. Not really right now.
If so, what church do you attend?
Please briefly describe the problem or situation, which led you to seek our help at this time: *
How long has this been a problem? *
Have you experienced this problem before? If so, when? *
Have you ever been to counseling before? If so, when? What, if anything, was helpful about that experience? *
Have you ever had medication prescribed for psychiatric or emotional difficulties? If so, what and when? *
Have any other biological relatives had problems similar to yours, or had any other psychiatric or emotional difficulties? *
What are your current symptoms? *

Very unhappy Withdrawn Daydreaming Impulsive Mean to others Sexual problems Stressed out Undependable Suicidal Thoughts Homicidal Thoughts Lying Financial Stress Self-mutilating Sleeping problems Hair pulling Parenting problems Grief Temper outbursts Employment problems Eating problems Alcohol Use/Abuse Crying spells Sexual abuse Physical abuse Emotional abuse Fearful Violence Relationship problems Drug Use Social Problems
Further explain your symptoms as needed.
Have you ever been physically, sexually, emotionally abused? If so, briefly describe. *
Have you ever been hospitalized for mental or nervous problems? If so, please explain. *
Have you ever attempted suicide? If so, where and when? *
Are you suicidal now? *

Yes No Not sure, but it has crossed my mind lately.
How often do you drink alcohol? *
Do you use recreational drugs? If so, what kinds and how often? *
Have you ever been arrested? If so, when and for what?
Are you currently involved or do you expect to be involved in any court related matters? *
What are your goals for counseling? *
As best as you are able, please try to articulate any concerns or fears you may have concerning entering into counseling? *
Is there any other important information you would think would be important for your counselor to know? *
Please select the quality that is most important to you in your counseling experience. *
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

HeartStrong Ministry