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Background Information
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DONATION
What is your placement in your family'?
Please select
1
2
3
4
5
6
7
8
9
10
Brothers' Ages
Sisters' Ages
Are you adopted?
Yes
No
Are any brothers or sisters adopted?
Yes
No
If yes, what are their ages and how many are there
If a twin, are you identical?
Please select
Yes
No
MILITARY SERVICE RECORD
Have you ever been in the military service?
Please select
Yes
No
If yes, what branch?
Were you in combat?
Any military honors or medals?
Type of discharge?
Education
What is the highest grade you completed in school and in what year?
What is the highest degree you have received? (Choose one) AA BA/BS MA/MS MSW MTh MDiv MBA RN LPN MD DD ThD PhD Other
Major in?
Minor in?
OCCUPATION
Your occupation
Your employer
How long?
Employer's address
Employer's telephone number
What type of work do you do?
If you could be anything or anyone you wanted, who or what would you be? (be specific)
Spouse's occupation:
Spouse's work telephone number:
How long has it been since you had a complete physical examination?
What physical disorder do you have, if any?
How many schools did you attend prior to any college?
Do you take medications?
List their names and purposes:
Do you take vitamins?
What kind?
Your favorite food?
Your favorite dessert?
How often do you eat it?
Do you snack often?
On what?
Do you use alcoholic beverages?
None
Some
Moderately
Often
Is there a family history of alcoholism?
Who?
Do you drink coffee?
Decaffeinate
Regular
How many cups per day?
Please select
Less than 3
More than 3
More than 6
Do you use tobacco regularly?
No
Some
Moderately
Heavy
Describe yourself in a few sentences
Which religion are you?
Please select
Christian
Islam
others
What is the name of your worship center, if any?
Are you a regular
frequent
occasional
infrequent
attendee
Have you ever thought of committing suicide?
Yes
No
If yes. explain:
Have you ever attempted suicide?
When?
Do you ever think that perhaps you're going crazy?
If yes, explain:
Do you ever simply want to run away?
Please select
Yes
No
If yes, explain:
Do you look forward to the future?
Yes
No
How do you feel about the past?
Good
Ok
Guilty
Bitter
Angry
Confused
Wish you could change it.
What time period do you think about the most?
Past
Present
Future
Is there a family history of physical or emotional abuse?
Yes
No
If yes. please explain:
Were you ever sexually abused or molested?
Yes
No
If yes, by whom?
Do you believe "your only problem” is the behavior of someone else? If yes, please explain:
So that we may understand your problems fully, please state in your own words the life area you need answers to and why you chose a Christian Counselor.
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Pearls Christian Counseling
To provide biblical counseling, hope and comfort for the hurting, vulnerable and unprivileged in our society.
Pearls Christian Counseling (PCC) is a registered 501(c) (3) organization. PCC Tax ID is available upon request.
info@pearlscc.com
Copyright by
Philech Global
. All rights reserved.
Copyright by
Philech Global
. All rights reserved.