Client Intake Form | ReCovering Peace

ReCovering Confidential Client Intake Form

Scott and Lisa Lind- Counsel & Mentoring

First name

Last name

Phone

Address

City, State and Zip Code

Birthday

Month

Day

Year

Ethnic Background

Religious Background

Current faith, belief system or church affiliation

Married

Separated

Widowed

Divorced

Single

Name of Spouse - if married

How many times have you been married

Children and Ages

Siblings (list in birth order)

Describe your childhood family

Describe your relationship with your birth father - if you are adopted your adoptive father as well.

Describe your relationship with your birth mother - if you are adopted your adoptive mother as well.

Describe your spouse

Describe your marriage

Describe your relationship with yourself - how do you feel about yourself?

Do you have any health issues?

Are you currently using any substances or medications to calm yourself?

What do you hope to accomplish in counseling? If you aren't sure that is ok.

Are you willing to take the time needed for healing work? Things like assignments, journaling, prayer, time with God? This should take about 30 minutes to an hour on average each day.