Adult Client Information

Full Name *

Birthdate *

Age *

Relationship Status *

Years Married

Years Divorced

Months Separated

Address *

City *

State *

Zip / Post Code *

Preferred Phone *

Cell Provider

Email *

Occupation

Education Level

GABC Church Member?

If No, Where Do You Currently Attend?

Spouse Full Name

Spouse Birthdate *

Age

Occupation

Education Level

Spouse's Preferred Phone

Cell Provider

Address

City

State

Zip / Post Code

Spouse's Email

GABC Church Member?

If No, Where Do You Currently Attend?

Children's Names and Ages

Are You A Blended Family?

His Children's Names and Ages

Her Children's Names and Ages

Children Together Names and Ages

Physician

Physician Phone

His Current Medications

Her Current Medications

Other Counselors Seen

*

ANXIETY
FAMILY ISSUES
PARENTING ISSUES
DEPRESSION
MARITAL ISSUES
RELATIONSHIP ISSUES
PRE-MARITAL COUNSELING
GRIEF

Have you been diagnosed by a medical professional?

If so, what was the dianosis?

Referred By

How Did You Learn About Graceworks? *

I give my counselor permission to contact me with any information or resources pertaining to my counseling:

Initials

* After you submit this form please visit the Counseling Forms Page to read and sign the "Counseling Procedures and Agreement" Form