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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 Couple Intake
New client information (Couple)
*By typing in my name and or initials below, I acknowledge that it is taking the place of my handwritten signature.
How did you learn about Level Ground Christian Counseling?
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Name (Him)
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Address
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City
*
State
*
Zip
*
Home
(###)
###
####
Cell
*
(###)
###
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Work
(###)
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Email
*
Best way to reach you?
Home phone
Cell phone
Work phone
Email
Occupation
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)
Are you currently taking any prescription medications?
*
Yes
No
If yes, what prescription medications are you 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?
*
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
Name (Her)
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
City
*
State
*
Zip
*
Home
(###)
###
####
Cell
(###)
###
####
Work
(###)
###
####
Email
*
Best way to reach you?
Home phone
Cell phone
Work phone
Email
Occupation
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
Are you currently taking any prescription medications?
*
Yes
No
If yes, what prescription medications are you 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?
*
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, as a couple, seeking counseling today?
Thank you!
