Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Married

Yes

No

Have you experienced a substantial change in weight over a relatively short period of time?

Yes

No

Have you ever had any psychotherapy or counseling before?

Yes

No

Are you presently taking any medication?

Yes

No

Have you ever taken drugs for other than medical purposes?

yes

no

Have you ever has a problem with alcohol or drug abuse (prescription or non-prescription?

Yes

No

Have you ever has a severe emotional upsat?

Yes

No

Do you have problems sleeping?

Yes

No

Are you a member of your church?

Yes

No

Are you in good standing?

Yes

No

Do you believe in God?

Yes

No

Do you consider yourself to be a Christian?

Yes

No

Do you pray to God?

Yes

No

Address/City/State/Zip

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is you spouse willing to come to Counseling?

Yes

No

Have you ever been separated?

Yes

No

Have either of you filed for divorce?

Yes

No

Is this your first marriage?

Yes

No

Date

MM

DD

YYYY