Living Renewal Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please answer to the best of your ability. Any question you feel uncomfortable answering, you can leave blank and discuss it with your counsellor.Name *Phone *CellEmailAddress (Residence #, City, State/Province, Zip/Postal Code)Occupation:Employer:Date of Birth:Age:Sex *MaleFemaleMarital StatusSingleEngagedMarriedSeparatedDivorcedRemarriedWidowEducation: ElementaryHigh SchoolGEDCollegeGraduateDegreeProfessionalOtherHobbies: How did you hear about us?If you were raised by anyone other than your own parents, briefly explain:How many siblings do you have?Older BrothersYounger BrothersOlder SistersYounger SistersOtherHow many of each? Name of SpouseSpouse's occupationSpouse's Phone #Spouse's ReligionSpouse's AgeSpouse's Education or Trade if Applicable Does your spouse know you are coming for counselling?YesNoIs your spouse willing to come to counselling if needed? YesNoUncertainHave you ever been separated? YesNoUncertainIf yes, when?State the date (days, weeks, months, or years of separation)How old were you both when you got married?How long did you know your spouse before marriage?Length of steady dating/engagement with spouse?If applicable, please give brief information about any previous marriages:Children Information: Please list the details about your children below Children Information: Please list the details about your children below | Name, birthdate, sex, education, marital status. * Please add an asterisk if any child is from your previous marriage.Have you dealt with severe emotional struggles in your past? YesNoIf yes, please briefly explain:Have you ever had any therapy or counseling before? YesNoIf yes, list dates:What was the result of your counseling, if applicable?Check off any of the following words which best describe you now: Self-confidentAnxiousMoodyOften SadImpulsiveExcitableCalmShyFearfulIntrovertExtrovertLikeableLonelyBitterHappyJoyfulList fears you haveHave you ever been arrested? YesNoHave you ever been arrested? If no, put N/AHow would you rate your health?Very GoodGoodAverageDecliningOtherApproximately how much sleep do you get each night?When do you go to sleep at night? When do you get up?Do you have any chronic medical conditions? When is the last time that you have been seen by a doctor for a physical?Are you presently taking prescription medications?YesNoPlease list:Are you presently taking prescription medications? | Health InformationHow much alcohol do you consume?DailyWeeklyOccasionallyVery littleNeverDo you engage in vaping or smoking any substances?DailyWeeklyOccasionallyVery littleNeverIn the past five years, have you used illegal or excessive prescription drugs? YesNoNot SureInstitutional church/house church/fellowship attended during childhood (if any):What institutional church/house church/fellowship do you now attend (if any)?City:Do you believe in God?YesNoUncertainDo you pray to God? YesNoOccasionallyDo you read your Bible?YesNoOccasionallyDescribe your personal and quiet time with God?Suppose you die today and God asks you why you should be allowed into heaven? What would you say? Does your family regularly read the Bible and pray together? OftenOccasionallyNeverReligious background of spouse:Explain any recent changes in your religious/spiritual life, if any: Zip/Postal give you How do you describe the issues with which you are struggling?What have you tried to do about them?How do you hope counseling might help? (What are your expectations in coming here?) What brings you here at this time? (Did any recent event cause you to schedule the appointment now?) Is there any other information you think we should know to help you? Closing Consent *I understand that Living Renewal is a faith-based biblical counselling service that combines deep engagement with Scripture, along with relational and spiritual perspectives. We aim to apply the wisdom of Scripture to real-life situations so you can walk in freedom, truth, and Christlike transformation.I consent to being contacted regarding next stepsDateSubmit
