Client Intake Form Date* MM slash DD slash YYYY Referred by: Name* First Last Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Home)Phone(Work)Phone(Cell)Employer* Position:* Gender* Male Female Age*Date of Birth MM slash DD slash YYYY Relationship Status:* Single Married Separated Divorced Widowed Religious Preference:* Church you belong to: Name and telephone number of significant other (or person to contact in case of emergency).* Relationship to you* Phone*Children’s names and ages:Child's NameAge I am seeking counseling and discipleship services for:* Individual Couple Family Group When?* Have you received counseling previously?* No Yes Name of your counselor:* State in your own words why you are seeking counseling at this time:*We do not give medical advice or recommendations about medications. We are trained to use the Scriptures to address difficulties for those who seek help.