Client Questionnaire

Before filling out the Client Questionnaire, please answer the following three questions.  If you answer yes to any of the questions, online and telephone counseling is NOT for you.

1. Are you seriously considering suicide?  If so, online and telephone counseling is NOT for you.  Please call the National Suicide Hotline at 1-800-784-2433, your local Suicide Hotline, or call 911.
   No Yes
   
   

2. Are you in the midst of a serious emotional crisis?  If so, contact a mental health professional in your local area.  Online and telephone counseling is NOT for you.
   No Yes
   
   

3. Do you have intense or serious emotional problems?  If so, contact a mental health professional in your local area.  Online and telephone counseling is NOT for you.
   No Yes

Last Name:

First Name:

Age: (required)

Email Address: (required)

Confirm Email Address:

Phone Number: (required for telephone counseling only)

Street Address:

City:

State:

Zip Code:

Gender:
Male:     Female:

Relationship Status:  Married: Single:   Divorced:   Widowed:

How did you find out about CounselingChristians.com?  What search engine or key words did you use?

Please describe the main reason you're contacting me- including a question.
(Take all the space you need.  This box will expand)

What would you like to gain from the counseling experience?
(Take all the space you need.  This box will expand)

Have you received any type of counseling services in the past?
Yes:   No:

If yes, please describe when and for what:

List all individuals living in your home (children, relatives, friends, etc.)
(Please list first name only, sex, age and relationship.  This box will expand.)

Do you have other children who do not currently live with you?
Yes:   No:

(If you do, please list their first name only, sex and age)

What important things about you or your family would be helpful for me to know?  (examples:  illnesses, handicaps, deaths, divorces, school/job changes, suicide -- box will expand)

Employment Status:
Employed full-time:

Employed part-time:

Full-time student:

Part-time student:

Unemployed:

Do you enjoy your work?
Yes:   No:   Somewhat:

Type of work you do:

Highest level of education achieved:

Some High School

Graduated High School

Some College

College Graduate

Some Post Graduate Schooling

Graduate Degree

Please list any major health problems you have:
(Take all the space you need.  This box will expand)

Please list any medications you take including the dosage.  Please include prescriptions, over-the-counter, herbal, homeopathic, medications and nutritional supplements:

Do you drink alcohol?  Yes:   No:

If so, do you drink:  Beer:   Wine: Mixed Drinks:   Hard Liquor:

If you do drink alcohol, how much and how often do you drink?

Less than 2 drinks weekly:

2-7 drinks weekly:

2-3 drinks daily:

More than 3 drinks daily:

Do you use any other substances?  Yes:   No:

Other relevant information regarding substances past or present:

IMPORTANT NOTE!!

By returning this questionnaire, I acknowledge that I have read the
 Client-Counselor Agreement and agree with all of the terms and conditions stated therein: