PASTORAL THERAPY ASSOCIATES
DATE:____________________________
TYPE OF COUNSELING Sought:
___INDIVIDUAL
___COUPLE
___FAMILY
___OTHER
REFERRED BY:____________________________
IDENTIFICATION DATA:
NAME:____________________________HOME PHONE:________________
ADDRESS:____________________________________________________
_________________________________ZIP CODE___________________
OCCUPATION:______________________BUSINESS PHONE:____________
DATE OF BIRTH:__________HEIGHT:________WEIGHT:______________
SEX: M__ F__RACE, NATIONAL OR ETHNIC ORIGIN:_______________
RELIGIOUS AFFILIATION:_______________
MARITAL STATUS: ______________ HOW LONG:________________
ACADEMIC EDUCATION (NUMBER OF YEARS):_______________________
OCCUPATIONAL TRAINING:______________________________________
MARITAL AND FAMILY DATA:
NAME OF SPOUSE:___________
SPOUSE'S DATE OF BIRTH:___________
ADDRESS:___________________________________________________
_________________________________ZIP CODE__________________
HOME PHONE:________________________________________________
OCCUPATION:______________________BUSINESS PHONE:___________
RACE, NATIONAL OR ETHNIC ORIGIN:___________________________
RELIGIOUS AFFILIATION:_____________________________________
ACADEMIC EDUCATION (NUMBER OF YEARS):______________________
OCCUPATIONAL TRAINING:_____________________________________
CHILDREN OF THIS MARRIAGE:
NAME AGE GENDER COMMENTS
SOURCE OF INCOME:_________________________________________
YOUR INCOME BEFORE DEDUCTIONS:____________________________
SPOUSE OR FAMILY MEMBERS' WEEKLY INCOME:__________________
TOTAL INCOME:_____________________________________________
FEE (DETERMINED BY THERAPIST):_____________________________
PREVIOUS MARRIAGES: YES NO
FORMER HUSBAND'S NAME(S) PRESENT DATE OF COMMENTS
AGE MARRIAGE
FORMER WIFE'S NAME(S) PRESENT DATE OF COMMENTS
AGE MARRIAGE
CHILDREN OF PREVIOUS MARRIAGE(S)
NAME AGE GENDER PARENTS COMMENTS
PLEASE MAKE A FAMILY TREE/MAP:
HEALTH DATA:
RATE YOUR PHYSICAL HEALTH (CIRCLE ONE):
VERY GOOD AVERAGE POOR
LIST IMPORTANT ILLNESSES, SURGERIES OR INJURIES WHICH HAVE CAUSED SERIOUS DIFFICULTY:
DATE OF LAST MEDICAL EXAMINATION:
LIST OR DESCRIBE ANY MEDICATION AND DOSAGE NOW BEING TAKEN:
YOUR PHYSICIAN:
ADDRESS:
PHONE:
PREVIOUS COUNSELING, PSYCHOTHERAPY OR SPIRITUAL DIRECTION (CIRCLE ONE): YES NO
IF YES, LIST NAME(S) OF COUNSELOR, THERAPIST OR DIRECTOR:
DATES AND NUMBER OF SESSION:
PREVIOUS SERIOUS MENTAL DISTURBANCE OR "NERVOUS BREAKDOWN" (CIRCLE ONE): YES NO
IF YES, WERE YOU HOSPITALIZED? YES NO
ARE YOU NOW OR HAVE YOU EVER BEEN ABUSED?
ARE YOU NOW OR HAVE YOU PREVIOUSLY BEEN ALCOHOL OR DRUG DEPENDENT?
RELIGIOUS AND/OR SPIRITUAL DATA
DO YOU CONSIDER YOURSELF RELIGIOUS? YES NO
DO YOU BELIEVE IN GOD? YES NO
DO YOU PRAY TO GOD? YES NO
DO YOU MEDITATE? YES NO
DO YOU READ SACRED SCRIPTURES (i.e., THE BIBLE, KORAN, COURSE IN MIRACLES, OTHER)? YES NO
HAVE THERE BEEN ANY CHANGES IN YOUR RELIGIOUS/SPIRITUAL LIFE RECENTLY? YES NO
HAVE YOU HAD ANY REMARKABLE SPIRITUAL EXPERIENCES?
YES NO
HAVE YOU FELT EXTREMELY CLOSE TO GOD OR A DIVINE PRESENCE?
YES NO
WHAT IS YOUR FAVORITE BIBLE OR RELIGIOUS STORY?
AS A CHILD?
WHAT IS YOUR FAVORITE MYTH OR FAIRY TALE?
AS A CHILD?
WHO IS YOUR FAVORITE HERO/HEROINE?
RELIGIOUS AFFILIATION IN CHILDHOOD?
BAPTIZED? YES NO
DO YOU ATTEND A CHURCH OR RELIGIOUS GROUP REGULARLY?
LIST PROBLEMS YOU WOULD LIKE TO DISCUSS IN THERAPY:
YOUR GOALS FOR THERAPY: