New Counselee Intake Form Name(required) Email(required) Cell Phone(required) Date(required) Address (City, State, Zip)(required) Occupation (required) Birthday (write age)(required) Sex(required) Male Female EDucation degree(required) High School GED College Degreee Religious Background Did you attend church as a child?(required) Yes No IF Yes, type the name of Church below: Do you attend church currently?(required) Yes No IF Yes, type the name of Church below: How many religious or church-related activities do you attend per month?(required) Do you consider yourself a spiritual person?(required) Yes No Uncertain Do you believe in God?(required) Yes No Uncertain Do you pray to God?(required) Yes No Uncertain How often do you pray?(required) Daily Weekly Not Often How often do you read the bible?(required) Daily Weekly Not Often How often does your family read the bible and/or pray together?(required) Daily Weekly Not Often Explain any recent changes in your religious/spiritual life, if any: Book Appointment Δ Share this:TwitterFacebookPinterestEmailLike this:Like Loading...
A Story For His Glory Ministries, Inc. 