Adult Personal Information Form - Hands of Hope America

No information leaves this office without signed release. All information is privileged and confidential to the extent permitted by law.

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Today's Date *

Would you like to receive our newsletter via email: *

Yes
No

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Client's Full Name *

Email *

Employer/School:

Preferred Name *

Occupation/Grade:

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Education Level:

Last Grade Completed

Last Grade Completed

Last Grade Completed

Completed?

High School
College
Graduate School

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Hours worked per week:

Estimated annual income:

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Current relationship status:

Please list significant relationships. (Ex: Married, Divorced, Widowed, Open, Dating, Separated, etc.)

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Relationship

Length of Relationship:

If applicable, current partner’s identified gender:

Male
Female
Other

What type of counseling are you seeking? Please choose one and note Forms Required.

Type | Description | Form Required *

Individual | One-on-One Counseling | 1 Intake Form per person
Family | Two or more family members | 1 Intake Form per person over 18 yrs.
Relationship | Dating couples | 1 Intake Form per person (2 total)
Pre-Marital | Engaged couples or those considering marriage | 1 Intake Form per person (2 total)
Marital | Couples needing marital guidance | 1 Intake Form per person (2 total)

# People living in Home: (List Below)

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Name:

Age:

Relationship:

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Primary Physicial/Psychiatrist: *

Phone *

List all current medications you are taking, including those you seldom use or take only as needed:

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Name of Medication(s)

Dosage

Reason for Taking

Have you or a family member ever been hospitalized for emotional disorders? *

Yes
No

Name/When/Where:

List names of previous counselors, therapists, or mental health programs, including dates and contact information:

How do you feel about the results of your previous counseling?

Spiritual Assessment

Satisfaction Level with Spiritual Life

Behavioral Demonstration of Spiritual Life • • • • • (i.e. prayer, meditation, devotion…)

Intentional Nurturing of Life in Spiritual Community • • • • • (i.e. worship, group study, retreat…)

God viewed from a Grace Perspective • • • • • (as opposed to judgmental)

How much influence does your spirituality have on your day-to-day activity?

None
Very Little
Some
A lot

What concerns have led you to pursue counseling? *

Where are your concerns causing the most problems for you? Check all that apply.

If Other Relationships, Specify:

When did your present concern begin to become a problem for you?

Have any concerns about you been identified by others?

Please a value on the scale below to indicate how distressing your problem(s) are to you.
1 = Minimally Distressing
5 = Moderately Distressing
10= Extremely Distressing

Distress Level

Distress Level: 1

Clicking SUBMIT will take you to the next form that is required.