SUSPENDED FORM

Name

Address

Email

Gender

Male Female

Home Phone

Cell Phone

Work Phone

Which number do you prefer prefer us to use for communications about scheduling or billing?

Home Cell Work

Date of Birth

Age

Racial/Ethnic Identity

Spouse
If applicable

Local Church

Employer

Job Title

Referred By

Requesting

Emergency Contact

Contact Phone Number

Relation to You

Will another party be involved in payment (Church, Sponsor, etc.)?

Ministry Mailings
*Please note that what is sent by email is different than what is sent by mail

Yes, I would like to receive emails about events and news for The Barnabas Center ministries and programs.‎ Yes, I would like to receive periodic mailings about the ministry (Barnabas newsletters, annual report, Christmas story, and end of fiscal year letter).‎

If different from above, please provide appropriate email address.

High School Grade Completed

Do you have a High School Diploma/GED?

Yes No

Business/Technical School

Course of Study

Name of College/University

Graduate?

Yes No

Major

Graduate School Name

Area of Study

Graduate?

Yes No

Current Relationship Status

If Single, are you in a significant relationship?

Yes No

If Married, Anniversary Date

Have you been previously married?

Yes No

If separated, divorced, or widowed, how long?

If you have children, please list their names, ages here

Previous Counseling

When

Counselor(s)

Reason then

Reason for counseling now

How long have you had these concerns

Medical

Are you currently taking any prescribed or non-prescribed medications?

Yes No

List current medications and dosage

Physician's Name

Physician's Phone

Please comment on any other physical problems that you would like us to know about:

Are you being treated for any medical concerns at this time?

Yes No

Recent losses, deaths of family/friends or other significant life change?

Yes No

If yes, please explain:

Present Concerns

Concern
Check all that apply

If Other, explain

Any other concerns or comments pertaining to your current circumstance:

1) You may have tried a number of things to cope with the issues that bring you to counseling now. Please describe what you have tried and how successful your efforts have been.

2) If our work in counseling is successful, in what ways do you think you or your life might be changed?

Indicate if you have any preferred counselors:

Lisa Ould‎ Andrea Mitchell‎ Kim Greene‎ Dan Carson‎