Counseling Intake Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneOkay to leave message at Home Work Cell Email* EmploymentAge*Level of EducationHigh School DiplomaSome CollegeBachelor DegreeGraduate DegreeCurrent Relationship Status*SingleMarriedSeparatedDivorcedRemarriedWidow(er)Living TogetherHow many years married?How many years divorced?How many years widowed?Partner's Name First Last Partner's AgeChildren's Names and Ages (if applicable)Are you bringing someone with you?*YesNoIf yes, is the other person a minor?YesNoWhat is your relation to this person?Other Person Name First Last Other Person Email How did you find the BBC Counseling Center, or who referred you?*Do you currently struggle with any behaviors that you or others might consider addictions?How would you rate your current physical health?*ExcellentGoodFairPoorAre you currently experiencing any physical problems? (i.e. headaches, body aches, stomach problems)YesNoIf yes, please explainBriefly describe your relationship with God.*Have you ever had any previous counseling experience?*YesNoIf yes, please describe the reason(s) for previous counseling.Have you ever had any serious thoughts about suicide?*YesNoHave you ever attempted suicide?*YesNoWhat current concerns have led you to pursue counseling?*In what areas of your life are your concerns causing the most problems for you? Check all that apply.* Home Work Marriage Relationship with God Other relationships Describe any strengths or weaknesses you feel you currently have.*Do you have any natural support (friends, relatives, etc.) that you are currently relying on? If yes, who?What days of the week and times of day work best in your schedule to meet?*Is there anything else you wish the counselor to know?