General InformationName of Child*Age*Gender* Female Male Birthdate*SchoolGradeAddress*City*State*Zip*Name of Parent:*Parent Phone*Parent Email* Enter Email Confirm Email Have parents been contacted regarding request for counseling?* Yes No Has your child had any professional counseling before?* Yes No Issue 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 Other If other please describe:What is your marital status?* Unmarried Married Separated Divorced Widowed Name of SpouseDate MarriedHave you previously been married? Yes No Do you have children? Yes No Do your children live with you? Yes No Please list the gender and ages of your childrenHave any life altering changes occurred within the past 2 years?* Yes No If yes, please describeSpiritual InformationHave you received Jesus Christ as your Savior?* Yes No Who do you call your church home?* We don't have one Mission Hills Calvary Baptist Other If other, where?Do you believe in God?* Yes No Do you believe your child has accepted Jesus Christ as their Savior?* Yes No Has your child been baptized?* Yes No How often do you read your Bible as a family?* Regularly Occasionally Never How often do you pray as a family?* Regularly Occasionally Never Is your child active in church?* Yes No If yes, please describeHealth InformationPlease rate your child's health* Very Good Good Average Poor Please 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 No If yes, please describeEmployment InformationAre you employed?* Yes No If yes, where?How long?Is your spouse employed?* Yes No If yes, where?How long?Scheduling PreferencesPreferred Appointment Day*Please note that all appointments will be based on the counselors' availability. Monday Tuesday Wednesday Thursday Friday Preferred Appointment Time* Early A.M. Late A.M. Early P.M. Mid P.M. Late P.M. CommentsThis field is for validation purposes and should be left unchanged.