Cindi's LGCC Minor Intake Form

Cart 0

Cindi's LGCC minor intake form

*By typing in my name and or initials below, I acknowledge that it is taking the place of my handwritten signature.

Today's Date

YYYY

How did you learn about Level Ground Christian Counseling?

Minor's Name

First Name

Last Name

Date of Birth

YYYY

Address

City

State

Zip

Home

(###)

###

####

Cell

(###)

###

####

Work

(###)

###

####

Father's Name

First Name

Last Name

Occupation

Father's Cell

(###)

###

####

Father's Email

Mother's Name

First Name

Last Name

Occupation

Mother's Cell

(###)

###

####

Mother's Email

What is the best way to contact you?

Home phone

Cell phone

Work phone

Name of your school?

Grade?

List all activities you are involved in (both in and out of school):

Religion

Local Affiliation (Church)

Are your parents divorced?

Yes

How old were you?

If they have remarried, please list any stepparents' names:

Please list your siblings and their ages

Where are you in the birth order

Are you currently taking any prescription medications? (If yes, please list the name of the medication(s) )

List any past or present medical issues

List any secondary issues (sleeplessness, panic attacks, phobias):

Date of Last Physical

YYYY

Do you exercise?

Yes

Are any significant events occurring at this time? (trouble in school, divorce or death in the family, etc))

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)

Are your parents...

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?