Pre Counseling Form Name * First & Last Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Age * Profile Picture Drop a file here or click to upload Choose File Maximum file size: 268.44MB Please attach a .jpg, .png, or .gif image. By attaching an image to use as your profile picture you assert that you have rights to use the image and it is not illegal, pornographic or violent in any way. Family Tree This section is to help the counselor determine relationships that are pertinent to the patient(s) needs. If one is seeking marriage support, maybe only a spouse is pertinent to list. If seeking support for blended families pertinent relationships could be spouses, ex-spouses, all kids what nuclear family they are from, etc… One could not give too much info here. IF MULTIPLE PEOPLE ARE FILLING THIS FORM OUT FOR THE SAME COUNSELING SESSIONS, ONLY ONE PERSON NEEDS TO COMPLETE THIS SECTION Name Relationship HusbandWifeSonDaughterDaughter of HusbandDaughter of WifeSon of HusbandSon of WifeBrother of HusbandBrother of WifeSister of HusbandSister of Wife Current Age Birth Date plus1 Add minus1 Remove Current Living Situation Medication Please list all medications below. Add as many rows as necessary. Drug Name Dosage Frequency Taking since Notes plus1 Add minus1 Remove Please describe any emotional events that have had or are having an emotional impact on you/your situation What is your desired outcome of meeting with a counselor? What brings you in today? What is the situation as you see it? Please share any additional information you feel may be valuable Submit If you are human, leave this field blank.
