Confidential Intake Form

Please complete each area fully.
IDENTIFICATION DATA
NAME
DATE
STREET
CITY
STATE
ZIP
HOME PHONE
BUSINESS
SPOUSE
EMAIL
OCCUPATION

Marital status

singleMarriedDivorcedRemarriedWidowed

How strongly do you want help for your problem? Circle one

Very muchmoderatelycould do without

I have talked about my problem with: Psychiatrist (MD) Psychologist (PhD)

Other professionslay counselorspastoral

If you have had previous counseling for this problem, state with whom and describe the outcome

Safe Harbor Counseling by

HEALTH INFORMATION

Rate your physical health:

Very goodGoodAverageDecliningOther

List all important present or past illnesses, injuries or handicaps

Date of last examination
Results

Have you used drugs for other than medical purposes?

YesNo

If yes, what?

Are you presently taking medication?

YesNo

What?

EDUCATION: (circle last year completed)

Grade school
12345678
High school
101112
College
123456+
Other training(list type and years)
Degree(s)
Dates

OCCUPATION

Present occupation
Age when you started working
How long have you been employed in this present job?
Does your present job satisfy you? If not, what ways are you dissatisfied?
Ambitions and aspirations (what are your goals, dreams, hopes)

Religious background

Name of church you are currently attending
Pastor’s name
phone
Have you consulted your pastor concerning this matter?
YesNo
Church attendance
per month (circle)0123456789
Baptized?YesNo
religious background of spouse
Do you consider yourself a religious person?
YesNoUncertain
Do you believe in God?
YesNoUncertain
Do you pray to God?
Neveroccasionallyoften
Are you saved or born again?
YesNo

Explain what being born again means to you

Do you believe God loves you?

Describe briefly how you view God

Describe briefly how God views you

MARRIAGE INFORMATION

If never married, Check here and omit this section
Is this your first marriage? YesNo
If no, how many times?
Name of spouse
length of marriage

issues causing Divorce

Name of spouse
Age
phone
Occupation

Is your spouse willing to come for counseling? YesNoUncertain

Have you ever filed for divorce? YesNo

Have you ever been separated? YesNo

What is your wedding date?

Your ages when you married:

husband
wife
How long did you know each other before marriage?
Length of engagement
How did you get along with your in-­laws (including brothers&sisters-­‐in law?)
Has anyone (parents, relatives and friends ever interfered in your marriage?
Place the letter “C” Or “I “below as it applies to present marriage (c=compatible, I= incompatible)
value system
commitment
devotion to spouse
devotion to children

intellect

sleep

financial planning

child discipline

Energy level

food appetite

spending

devotion to work

social time

exercise needs

recreational interests

household duties

planning

sexual needs

parenting style

in-­law relationships

neatness

need for time alone

sensitivity to feelings

friends

conversation

spiritual growth

What I like in the last few months:

What I disliked in the last few months:

Give specific examples of those things you would like to see your spouse do more often (ex. Take out garbage, spend more time etc.):

Give specific examples of things you would like to see your spouse stop doing (those particular things that irritate you)

Dream about your marriage future

You can’t accomplish your dreams because

PARENTAL FAMILY HISTORY

If you were reared by anyone other than your biological parents, briefly explain:

Are your parents living?

Father:YesNo
Mother: YesNo
Occupation of father
Occupation of mother

Are/were they Christians?

Father: YesNo
Mother :YesNo
Are they living together? YesNo
Are they divorced? YesNo
Are they remarried YesNo
How is your relationship with your step parents?
Rate your parents’ marriage:UnhappyAverageHappyVery Happy
How was your relationship with parents growing up?
How is your relationship at the present time?
As a child did you feel closest to FatherMother
Rate your childhood life:UnhappyAverageHappyVery Happy
Describe the atmosphere in your home when you were a child (ex: tense, peaceful, and fighting)

How would you describe your family’s financial situation when you were a child: check one? Poorslight financial strugglemoderate incomeaffluent

Describe briefly your relationship with father:
Mothers condition (emotional & physical ) during pregnancy with you:
Do you know if your mother suffered any trauma during pregnancy with you?
YesNo
How did mom react to the news that you were going to be born?
How did Dad react?
Father Current age
Mother Current age
His personality :
Her personality :
His values
Her values
Kind of environment he provided
Kind of environment she provided
Describe your fathers relationship with mother
Describe your mother relationship with father
Who was actually in charge? (Head of the house)

Describe his relationship with children

Describe her relationship with children

How did he show love

How did she show love

What was his ambition for his children

what was her ambition for the children

Describe your ability to confide to him

Describe your ability to confide to her

Form of punishment

Form of punishment

As a child, what I liked about him

as a child what I like about her

Who was your dad’s favorite

who your mom’s favorite was

Was your father (check):
Have you ever felt rejected or abandoned by your parents?
YesNo
Do you feel you have let your parents down?
YesNo
Did your parents influence your career choices?
YesNo
Did either of your parents suffer from depression?
YesNo
Has any parent, sibling, grandparent suffer from a mental problem? Who? What was the problem?





Addictions/use
alcohol
spending
nicotine
sex
stealing
work
Compulsive exercise
Co-­dependency
gambling
pornography
drugs
food
sports
Tv
computers
Do you, or have you ever had any obsessive-­compulsive behavior patterns?
YesNo
if so what?

A. Are any of the following beliefs, patterns or traits characteristic in your life? (check all that apply)

i am not speciali do not have the same standing as othersothers are smarter than meothers do better than meothers are more important than mei am not good at anythingi cannot or will not speak or laugh in publicno one cares about mei can not be taught anything

Headachesdizzinessfaintingspellspanic attacksanxietiesfeel tenseunable to relaxdepressionSuicidal tendenciesinsomnia nightmares stomach orbowel disordersno appetitefinancial problemsAlcoholism drugs/sexualaddictions pornographysexual difficultiesunable to have a goodtimeAlcoholism drugs/sexualaddictions pornographysexual difficultiesunable to have a goodtimeDo not like weekends vacationsover-­ambitiousshy with peoplecan’t make friendscan’t make decisionscan’t keep a jobperfectionistunworthy controllingdifficult to praylow energyFear Godfear successfear failureverbal abuseabortionsfeel invisibleflea worshippleaser Moodinessunhappy childhoodbody imagedifficult to read bibleworryobsessive grief Frustrationsee life as goodsee life as badnot listened toguilt feelingswish born another timeDislike confrontations peacemakerangry insecurityflashbackssee God asdistant flooded byFeelingscan’t express feelingunable to hold boundarieshard to tell right from wrongInadequatelonelyfear travelbullied as childmiscarriagesflashbacksimpatienceIrritabilitytempersrebellion violence stubbornnessworrierunbeliefconfusionlustful -­ thoughtsadultery fantasies

Are you a critical person? YesNo

Do you feel emotionally immature?YesNo

Low self-­‐imagefeel insecuresometimes condemn myselfhate myselffeel worthlessBelieve i am a failurefeel inferiorquestion my identity

punish myself (if so, how?)
Has lying or stealing been a problem for you?
Is it now? YesNo
Were you a lonely teenager?
YesSometimesNever
explain
As a child, teenager or later in life, did you ever suffer an injustice? What and by whom?
Do you have trouble giving or receiving love?
YesNo
Do you find it easy to communicate with persons close to you?
I have difficultyiam unwillingi have some problems, at timesits easy
Are you a perfectionist?YesNo
were your parents’
perfectionists? YesNo
Have you been given to swearing? YesNo
obscenities? YesNo
Do you toward anyone have?
Forgiveness? Whom and why?
Resentment? Whom and why?
Bitterness? Whom and why?
Hatred? Whom and why?
Are you easily frustrated? YesNo
Do you show it or bury it? YesNo
Were you ever sexually molested or raped? When? By whom?
Or me school was
My role in my group of friends was
Describe yourself
do you spend your free time?
What kind of fun is included in your life?
Describe your spouse
What is the main problem as you see it? Why are you here?
What have you done about it?
What do you expect we can do?
there any other information we should know?

The information given in this personal data inventory has been provided voluntarily. I understand that this information is to be confidential; however, it may be used by Safe harbor counseling and their consultants and or facilitators as a basis for evaluating my spiritual needs and providing biblical direction for my life.