WELCOME TO NEW HOPE COUNSELING

To help me serve you better, your cooperation in completing this questionnaire will be helpful in planning our services for you. You can fill in the form and print or send a copy back to via by pushing the submit button. It is probably good to print out a copy in case it doesn't get to me and bring to the session with you. You can also fax it back to me at 425-334-2427.

PERSONAL INFORMATION

Full Name:

Street Address:

City:

Home Phone:

Birthdate:

EDUCATION

Type of Employment:

Person who does not live with you to contact in emergency:

How were you referred to us?

Briefly Describe Your Reason for Seeking Help:

MEDICAL INFORMATION:

When were you last examined by a physician?

Name of your primary care physician:

List any major health problems for which you currently receive treatment:

List any medication you are now taking and dose:

Have you ever received psychiatric or psychological help or

counseling of any kind

before?

PROBLEM LIST

Please add any information that might be helpful to your counseling

YOUR FAMILY MEMBERS

Family of Origin

Marital History

Children

Spiritual History

Today's Date:

State: Zip Code:

Only type in the numbers that you want me to call you at.

Cell Phone: Work Phone:

Martial Status: Spouse's Name:

If you are currently enrolled as a student select the following:

Elementary Middle/Jr. High High School Select grade:

If you have completed your education select the following degrees you have completed:

High School Diploma

Associate Arts in

Bachelor's in

Masters in

PhD in

Years Employed:

Name Phone Relationship

Problem List Please circle any of the following problems which pertain to you:

Depression Shame Meaninglessness Guilt Crying Spells Shyness

Sexual Problems Fears Separation Divorce Suicidal Thoughts

Drug Use Alcohol Use Finances Anger Self Control Friends

Sleep Anxiety Unhappiness Relaxation Stress Work

Legal Matters Headaches Tiredness Energy Memory Ambition

Nervousness Loneliness Insomnia Making Decisions Education My Thoughts

Inferiority Concentration Temper Career Choices Health Problems

Burnout Nightmares Marriage Unresolved Grief Stomach Trouble

Weight Gain or Loss Being a Parent Appetite Spiritual Problems

Include all persons who live in your home including your spouse and your children, and/or anyone living with you for whom you assume personal or family responsibility, and also any children no longer living in your home.

Family Information

Name Relationship Age Birth date Profession

________________________________________________________________________

Spouse's Name Length of Marriage Length of Engagement

Divorced Separated

Name Age Birthdate School

1. No church affiliation

2. Church affiliation

Protestant Denomination

Roman Catholic

Jewish

Orthodox Christian

Other Religion

3. What is the name of the congregation you belong to?

4. How involved are you in your congregation?

Attendance: Never Sometimes Regularly

5. Have you had a recent changes in your spiritual life? If yes, please explain

Thank you so much for filling out this information sheet. You might want to print this in addition to submitting it to me. Please bring the printed form with you as well.

Thank you,

Erik Bohlin, M.A.