COUNSELING FORMSGeneral InformationName of Child*Age*Gender* Female MaleBirthdate*SchoolGradeAddress*City*State*Zip*Name of Parent:*Parent Phone*Parent Email* Enter Email Confirm Email Have parents been contacted regarding request for counseling?* Yes NoHas your child had any professional counseling before?* Yes NoIssue seeking counseling for:Extent of NeedExtent of Need* Life Threatening Severe Mild Normal** If you are in a life threatening situation, please dial 911 or contact your local authorities. **What have you attempted or done to resolve this problem?*Please describe if there are any person(s), situation(s), or activities that seem to trigger this problem or make it worse:*Parental / Family / Custody InformationWhat is your relation to the child?* Parent Family Member Primary Custody Holder OtherIf other please describe:What is your marital status?* Unmarried Married Separated Divorced WidowedName of SpouseDate MarriedHave you previously been married? Yes NoDo you have children? Yes NoDo your children live with you? Yes NoPlease list the gender and ages of your childrenHave any life altering changes occurred within the past 2 years?* Yes NoIf yes, please describeSpiritual InformationHave you received Jesus Christ as your Savior?* Yes NoWho do you call your church home?* We don't have one Mission Hills Calvary Baptist OtherIf other, where?Do you believe in God?* Yes NoDo you believe your child has accepted Jesus Christ as their Savior?* Yes NoHas your child been baptized?* Yes NoHow often do you read your Bible as a family?* Regularly Occasionally NeverHow often do you pray as a family?* Regularly Occasionally NeverIs your child active in church?* Yes NoIf yes, please describeHealth InformationPlease rate your child's health* Very Good Good Average PoorPlease list any significant illnesses, injuries, or handicapsPlease list any medications they are currently takingHas your child ever experimented with or is taking illegal drugs?* Yes NoIf yes, please describeEmployment InformationAre you employed?* Yes NoIf yes, where?How long?Is your spouse employed?* Yes NoIf yes, where?How long?Scheduling PreferencesPreferred Appointment Day*Please note that all appointments will be based on the counselors' availability. Monday Tuesday Wednesday ThursdayPreferred Appointment Time* Early A.M. Late A.M. Early P.M. Mid P.M. Late P.M.PhoneThis field is for validation purposes and should be left unchanged.