Individual Intake Form Step 1 of 3 - Client Profile 33% A. Client ProfileFull Legal Name First Middle Last Suffix Preferred Name First Last Date of BirthSocial Securtiy Number: (secured)Best Contact NumberAlt Contact NumberOK to Leave a Voice Mail?YesNoEmail Address Street Address City County State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Partner NameCo-Parent's NameChildren? Check if applicable Children's Name and Date of Birth Child's Name Child's Date of Birth Edit Delete There are no Children. Add Child Maximum number of children reached. Place of EmploymentHighest Grade CompletedMilitary ServiceIn Case of EmergencyEmergency Contact Name Last Emergency Contact PhoneRelationship to YouHow did you hear about The Center for Family Resolution?If referred, by whom?May I have permission to thank this person for the referral? Yes No B. General QuestionnaireBriefly describe the reason(s) you are seeking coaching/counseling:Give the current roadblocks in the way of the above accomplishment:Tell me what you most appreciate about your current situation:List your family's strengths: List your strengths: Who are your best supporters?How do you take care of yourself?Briefly describe your general health, including any medications you are currently taking:Are you currently experiencing anxiety, panic attacks or phobias?Are you currently experiencing any chronic pain?What is your primary source of stress relief?Briefly describe your habits for sleepin / eating / exercise:Briefly describe you habits for alcohol / recreational drug use:What additional background information can you provide that you think would be most helpful to me when coaching / counseling with you? C. Family Health HistoryIn the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided ( father, grandmother, uncle, etc. )Alcohol/Substance Abuse Yes No Family member relationship: Bi Polar Yes No Family member relationship: Depression Yes No Family member relationship: Domestic Violence Yes No Family member relationship: Eating Disorders Yes No Family member relationship: Anxiety Yes No Family member relationship: Obsessive Compulsive Behavior Yes No Family member relationship: Schizophrenia Yes No Family member relationship: Suicide Attempts Yes No Family member relationship: Other:Have you previously met with a coach / counselor? This iframe contains the logic required to handle Ajax powered Gravity Forms.
