Pastoral Counseling Intake Form – Lifespan Ministries

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone (mobile)*

Phone (work)

Phone (home)

Is it ok to leave a message on the answering machine at work?

Is it ok to leave a message on the answering machine at home?

Age*

Birth Date*

Sex*

Social Security Number*

Marital Status*

Who lives with you?*

Emergency Contact Name*

Emergency Phone*

Education (highest level completed?)*

Currently a student?*

Employed?*

Occupation

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Please check the areas you feel you need help with (you may select more than one)*

Other

Please further describe the above checked concern(s)

Are you presently working with a therapist?*

Therapist's name

Name of facility

Length of period in therapy

Are you currently taking medication?*

Type of medication

How did you hear about Rev. Dr. Clardy?