Client Demographics and Presenting Concerns
Indicates required field
Full Name of Person Filling Out This Form
Name(s) and Date(s) of Birth for Person(s) Receiving Therapy
Your Relationship to Persons Receiving Therapy
If the person receiving therapy is under the age of 18, are you their parent or legal guardian?
Is this Email Address Confidential?
Please do not email me anything
OK to receive texts?
I prefer the therapist to contact me by:
What type of counseling will this be?
Would prefer to work from a Christian perspective in counseling
Would prefer a Non-Religious or Secular approach to counseling
Would like to discuss this with you at our first meeting
Check any or all that apply to your circumstances
Adult Mental Health Concerns
Child or Adolescent Mental Health Concerns
Child Behavior Problems
Child Academic Concerns
Childhood Physical or Sexual Abuse
Conflict with Friend or Family Member
Coping Skills Needed
Considering Leaving your Spouse or Partner
Divorce or Separation
Fear of Abandonment
Grief or Loss of a Loved One
Lonliness/Lack of Social Support
Loss of a Child
Loss of a Parent
Major Life Transition
Military Life: Deployment, Living Arrangements
Need Help Making a Major Life Decision
Parent of a child with autism or special needs
Previous Mental Health Diagnosis
Previous Mental Health Hospitalization
Recent Job Loss or Employment Concerns
Resentment/Unable to Forgive
By clicking this box, I attest that I understand that all information shared with Creekside Christian Counseling is kept strictly confidential by law, that I am the person listed at the top of this form, that I have submitted this information of my own free will, and that it is accurate and correct to the best of my knowledge.
I understand that when submitting personal information on-line, there is always a risk of a third party either intentionally or unintentionally accessing my information. Creekside Counseling ensures the security of your protected health information with industry-standard HIPAA-Compliant data security upon receipt by the counselor, but during transmission from me to the counselor and/or if I indicate a preference for the counselor to respond to my request via text or email, I understand that my information could be intercepted by a third party. By checking this box, I am indicating that I choose to accept this risk for the purposes of transmitting this form.
I have read, understood and agree to the above terms and conditions.