Fishers Farm Application
1 year residential program
Personal information
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facebook
Instagram
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Married
Single
Divorced
Education
*
Please Select
Middle School
High School
GED
College
Other Training/ Work Experience
*
Referred to Fishers Farm by
Health
Rate your health
*
Please Select
Very Good
Good
Average
Declining
Weight changes in the last six months
*
List all important present or past illnesses, injuries or handicaps:
*
Date of last medical examination
*
-
Month
-
Day
Year
Date
Report
*
Do you take medications
*
yes
no
If yes, please list them
Do you use Alcohol or other drugs?
*
yes
no
If yes please list them?
Have you ever been arrested?
*
yes
no
If yes please explain
Have you used drugs for other than medical purposes?
*
yes
no
Have you had a severe emotional upset?
*
yes
no
If yes please explain
Have you recently suffered the loss of someone close to you?
*
yes
no
If yes please explain
Have you recently suffered loss from serious social, business or other reversals?
*
yes
no
If yes please explain
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Church Background
Church attendance (years)
*
Church attended
*
Are you a member?
*
yes
no
Serving in a ministry?
*
yes
no
If so, please explain
Baptized
*
yes
no
Do you attend a regular small group or Life Group?
*
yes
no
Do you believe in God?
*
yes
no
uncertain
Are you saved
*
yes
no
not sure what you mean
How often do you pray to God?
*
never
rarely
occasionally
often
How often do you read your Bible?
*
never
rarely
occasionally
often
How often do you have regular family devotions?
*
never
rarely
occasionally
often
Explain any recent changes in your spiritual life
*
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Counseling
What do you think counseling is all about?
*
Have you ever had any psychotherapy or counseling before?
*
yes
no
If yes, list counselor or therapist and dates
What was the outcome?
What kind of involvement do you think a counselor should have in your life?
*
CHECK ANY OF THE FOLLOWING WORDS WHICH BEST DESCRIBE YOU NOW:
*
active
ambitious
self-confident
persistent
nervous
hardworking
impatient
impulsive
calm
moody
often-blue
excitable
imaginative
serious
easy-going
shy
good natured
introvert
extrovert
likeable
leader
quiet
hard-boiled
submissive
lonely
self-conscious
sensitive
Type a question Have you ever felt people were watching you?
*
yes
no
Do you ever have difficulty distinguishing faces?
*
yes
no
Do colors ever seem too bright?
*
yes
no
Do colors ever seem too dull?
*
yes
no
Are you sometimes unable to judge distance?
*
yes
no
Have you ever had hallucinations?
*
yes
no
Are you afraid of being in a car?
*
yes
no
Is your hearing exceptionally good?
*
yes
no
Do you have problems sleeping?
*
yes
no
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MARRIAGE AND FAMILY INFORMATION
Name of spouse
First Name
Last Name
Spouse's Phone Number
Address of spouse
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse's occupation
Spouse's age
Is spouse willing to come for counseling?
yes
no
Spiritual background of spouse
Have you ever been separated?
yes
no
If so, when?
Date of marriage
Your ages when married
Husband
Wife
How long did you know your spouse before marriage?
Length of steady dating of spouse before marriage?
Length of engagement?
Give brief information about any previous marriages
INFORMATION ABOUT CHILDREN
List Your Children and Their Ages
Briefly describe how you grew up
*
If you were raised by anyone other than your own parents, briefly explain
Number of Older Brothers
*
Number of Older Sisters
*
Number of Younger Brothers
*
Number of Younger Sisters
*
If there is any other family information that you feel would be helpful to know, please explain
BRIEFLY ANSWER THE FOLLOWING QUESTIONS
1. Describe why you are seeking help
*
2. What have you done to deal with the problem?
*
3. What can we do? (What are your expectations in coming here?)
*
4. As you see yourself, what kind of person are you? Describe yourself.
*
5. What, if anything, do you fear?
*
6. Is there any other information we should know?
*
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