New Client Confidential Intake Form To schedule an appointment with Sovereign Joy, please fill out our new client form. All information is confidential and is used to help the counselors prepare for your first session. Upon completion you will be contacted about setting up a date and time convenient for you for your first session. Please enable JavaScript in your browser to complete this form. - Step 1 of 5General InformationDateName *FirstLastGenderMaleFemaleAgeAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Occupation / EmployerHow long at current employment?Emergency Contact. Please include name, relationship and phone number. *NextRelationship InformationMarital StatusSingleIn RelationshipEngagedMarriedDivorcedSeparatedWidowedName of Spouse/FianceeTime Together?How long did you know your spouse before marriage?Is your spouse willing to come for counseling?YesNoUncertainHave you ever been separated?YesNoIf yes, when and how long?Please give a brief summary of any previous marriages. Include spouse's name, length of marriage, reason for divorce and any children from the marriage.PreviousNextSpiritual / Religious InformationDo you consider yourself a religious person?YesNoDo you regularly attend or are you a member of a local church?YesNoAttend infrequentlyPastor's NameMay we contact him about your counseling sessions?YesNoWere you reared in a religious environment?YesNoHave you received Jesus Christ as your personal savior?YesNoUncertainNot sure what you meanDo you spend regular time reading/studying God's word?YesNoSomeDo you pray to God?YesNoSometimesWhat do you pray about?Do you read scripture and pray with your spouse?YesNoSometimesPlease note any recent changes in your spiritual lifePreviousNextHealth InformationHave you had counseling before?YesNoHave you seen a psychiatrist before?YesNoCurrentlyAre you currently taking any psychotropic medications? (Prozac, Wellbutrin, etc.)Approximately how many hours of sleep do you get each night? Selected Value: 0 Do you go to sleep and wake up at a regular schedule?YesNoRarelyDescribe any recent changes in your sleep habits.Overall state of healthVery GoodGoodAverageDecliningOtherPlease explain any recent changes in healthHow would you describe your diet?Very GoodGoodAveragePoorHow regularly do you exercise?DailySeveral times a weekSeveral times a monthRarelyPreviousNextAbout Your ConcernsPlease check any of the following struggles that currently apply.Abuse, Verbal/EmaotionalAbuse, SexualAbuse, PhysicalAbuse, SpiritualAddictionAngerAnxietyApathyBitternessChild ManagementCodependencyCompulsionsConfusionControlDepressionDoubtDiscontentmentDivorceEating DisorderFailureFearFinancial ProblemsFriendship ProblemsGreedGriefGuiltHomosexualityHumilityIdentityImpulsivityInsecurityJealousyMoodinessPanic AttacksParentingPeer PressurePerfectionismPornographyPrideProcrastinationPridePurposeRejectionRelationshipsSame Sex AttractionSelf HarmSelf ControlShameSocial AnxietySpiritual GrowthSubmissionSuicidal ThoughtsOtherPlease list and explain any issues not covered above.Please describe your current problem, as you understand it.What have you done about it (most effective and least effective)?Other than counseling, what help are you seeking?Who referred you to this ministry for help?Please describe any family history (the family you grew up in) which might be pertinent to the concerns that you bring to counseling (your relationship with your parents, their relationship with each other, significant losses or event):What are your expectations coming here?What, if any, are your concerns about coming to counseling?What do you believe you will have to change to see the progress you desire?Is there any other information we should know?PreviousMessageSubmit