General Information

Your Name

Your Address

Your City

Your Province or State

Your Postal Code

Your E-Mail Address *

Your Age and Gender

Your home phone number

Your work number

Your cell phone/pager

Your date of birth

Two Emergency Contacts: (Due to the long-distance factor, these must be verifiable and they are mandatory in the event that there is some sort of crisis and we are unable to reach you. You could name your family physician and trusted relative/friend)

Name:

Address:

Phone/Cell/Pager/Email:

Name:

Address:

Phone/Cell/Pager/Email:

Marital History

Marital status

How long did you know your marriage partner before engagement?

How long have you been married?

Husband's/Wife's age?

Occupation of husband/wife.

Describe the personality of your husband or wife in your own words.

In what areas is there compatibility?

In what areas is there incompatibility?

How do you get along with your in-laws?

How many children do you have?

Please list their names, gender and ages.

Do any of your children present special problems? If so, please describe briefly.

Any history of miscarriages or abortions?

Comments about any previous marriage(s) and brief details

With whom are you living with now? (list names, age, relationship to you, occupation, if student, indicate grade school, high school, etc.)

List 3 people not mentioned above who are important to you, closest friends (first names only)

Education

Last grade completed and date.

Degrees or special courses completed and date.

Occupation

Your current occupation

Age of when you first started working.

Jobs held from earliest to most recent and how long in most recent.

Does your work satisfy you? if not, why?

What would you consider your family income: adequate, moderately adequate, or inadequate?

Describe ambitions or goals

What do you like to do is your spare time?

Name any organizations, churches, social clubs that you are involved with.

Clinical

Describe your problem(s). Please be as specific as possible. Use particular examples of how the problem manifests itself. State in your own words, the nature of your chief concern(s). If your problem is something that you think happens too often, state approximately how often it occurs, how long it lasts, and any other information you feel might be helpful in understanding it.

If your problem concerns something not happening as often as you would like, state what you would like to see happen more often, how often you think it should occur, etc. How would you rate the severity of the problem-mildly upsetting, moderately severe, very severe, extremely severe, or totally incapacitating?

If you have had previous counseling for this problem, state with whom and describe how the counseling was approached and the results.

Who else have you discussed this problem with?

Developmental History

Place of birth

What age did you leave home?

Under what circumstances?

Rate your current health. (Good, Average, Poor)

Do any health issues relate to your present problem(s)?

List any prescription medications you are currently taking including dosage, frequency, prescribing physician and reason for treatment.

When was the last time you felt physically and emotionally well?

Have you ever experienced serious depression? Provide details.

Have you ever attempted suicide or thought of it? Provide details.

Have you ever intentionally injured yourself or someone else? Provide details.

Assess how motivated you are to work through your problem(s)? (very, moderately, minimal)

Sexual background

Describe your parent's attitudes toward sex (ie: How was sex education approached? Was the subject discussed, etc.)

Have you ever experienced anxiety, guilt, or trauma from a sexual experience with a member of the opposite sex? If yes, please explain.

Have you ever experienced anxiety, guilt, or trauma from a sexual experience with a member of the same sex? If yes, please explain.

Please state any concerns about sexual issues- past, present, or future concerning sexual identity.

Family Information

List all brothers and sisters from oldest to youngest, including yourself, miscarriages, abortions, adoptions, etc.

What is your relationship like with your siblings, past and present

State your father's name, occupation, health. If deceased, cause of death and at what age and your age at the time. ("Father" here is your biological father. If some other male acted as a father figure predominantly in your life, provide info about your biological father first and then the father figure) What kind of person was he?

What was his relationship with you and your siblings?

As a child, the things I liked and disliked about Dad were:

State your mother's name, occupation, health. If deceased, cause of death and at what age and your age at the time. ("Mother" here is your biological mother. If some other female acted as a mother figure predominantly in your life, provide info about your biological mother first and then the mother figure) Also describe her- what kind of person was she?

What was her relationship with you and your siblings?

As a child, the things I liked and disliked about Mom were:

Describe your relationship with your Father

As a child, in what ways were you punished or disciplined by your parents?

Give your overall impression of your home atmosphere growing up:

Were you able to confide in your parents?

The most important values in our family were:

What stands out most for me about my family life is:

My parent's relationship to each other was:

If not brought up by your parents, who raised you? From what ages?

Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.? If so, provide details.

Does any member of your family suffer from alcoholism, drug addiction, or anything you would consider to be a "mental disorder"?

Has any member of your family been involved in criminal activity?

Are there any members of your family that may have an impact or could be relevant to your present problem? If so, please describe.

List any fearful or distressing experiences not previously mentioned.

Spiritual History

Do you attend church? Regularly? Occasionally? What denomination? Involved in Ministry? Have you experienced a personal relationship with God?

Have you accepted Jesus Christ as your Saviour?

Describe your family member's religious beliefs:

Self-Description

In what kinds of situations do you most readily lose self-control? Please provide specific examples (ie. Temper, uncontrolled crying, impatience)

In which situations are you best able to keep self-control?

How would you be described by: Your spouse? Your best friend? Your worst enemy?

How would you describe yourself?

What do you expect to accomplish from therapy, and how long do you expect therapy to last?

What feelings, thinking, or behaviour do you wish to change?

Please list all of the following that apply to you: Depression, Low energy, Low self-esteem, Poor concentration, Hopelessness, Worthlessness, Guilt, Sleep disturbance, Phobias, Appetite disturbance, Thoughts of hurting yourself, Thoughts of hurting someone else, Isolation/social withdrawal, Sadness/loss, Stress, Anxiety/panic, Obsessions/compulsions, Easily agitated, Confusion, Anger/frustration, Excessive use of alcohol and/or drugs, Physical Abuse, Sexual Abuse, Spousal Abuse, Feelings of inferiority, Relationship problems, Feelings of unreality, Difficulty trusting.

Please provide any other information that you believe is significant or make notes to discuss with your counsellor.

Legal disclaimer

You agree that the use of any or every part of the service is entirely at your own risk. This service is not intended for individuals who are planning to harm themselves or others. If the above is the case, please contact the relevant crisis hotline in your area. Services are provided "as is," without warranty of any kind, either express or implied, including without limitation any warranty for information, services, counselling, uninterrupted access, or products and services provided through or in connection with the service. You recognize that there are no guarantees as to the success of your relationship with the counsellor through this website, and you recognize that during the process of the therapy, psychological pain and distress can arise as difficult issues are addressed and worked through. You also acknowledge that, although Emerge Family Ministries has taken a number of steps to ensure the confidentiality of your communications with the counsellor, this service cannot guarantee the security of your communications through this website. You agree that the information on this form may be published at a later date although no real names would be used. I agree to forever release, discharge and indemnify George Sukhdeo and Emerge Christian Counselling Centre from all actions, suits, claims arising from receiving counselling on this site.

If you accept the terms of the above disclaimer, please check the box below and then press submit.

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