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Marriage Retreats
Israel 2026
Why We Exist
Podcast
Workshops & Seminars
Referral Partners
Scheduling
Contact
Cart
0
Marriage Retreats
Israel 2026
Why We Exist
Podcast
Workshops & Seminars
Referral Partners
Scheduling
Contact
Cindi's LGCC Individual Intake
*By typing in my name and or initials below, I acknowledge that it is taking the place of my handwritten signature.
Today's Date
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How did you learn about Level Ground Christian Counseling?
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Name
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First Name
Last Name
Date of Birth
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Address
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City
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State
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Zip
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Home
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Cell
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Work
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Email
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Best way to reach you?
Home phone
Cell phone
Work phone
Email
May we send you emails and or texts for upcoming workshops, groups, classes, and podcasts?
Yes
No
Occupation
Insurance Provider
Employer
Education Completed
Are you currently in school?
Yes
No
Religion
Local Affiliation
Marital Status
Single
Live-in
Engaged
Married
Separated
If engaged or married, what is your wedding date?
Number of previous marriages:
Children's Name(s) and Age(s)
Please list names and dosages of prescribed medications you are currently taking
List any past or present medical issues:
List any secondary issues (sleeplessness, panic attacks, phobias):
Date of Last Physical
MM
DD
YYYY
Do you exercise?
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Yes
No
Are any significant events occurring at this time? (e.g. job loss, death in family, financial trouble)
List any emotional issues that are present (anger, anxiety, moodiness):
Do you have any history of:
- Alcoholism/Drug Abuse - Depression, Manic/Depression - Schizophrenia - Other mental illness (please explain) - Emotional, verbal, physical, sexual abuse (please explain) - Other significant childhood traumas (please explain)
Family History
Are your parents...
Separated
Divorced
Remarried
Father Deceased
Mother Deceased
If yes to any of the above, please indicate your age at the time
Birth order: I was born the ____ of ____ children
Example: I was born the 2 of 4 children
Why are you seeking counseling today?
Thank you!
