Agape Counseling
St. Charles First Assembly of God
Initial Session Information

 Name:    Address: 

City:    Zip: 

Phone:   Cell Phone:

Sex:    Birth Date: 

Marital Status:   

Marital Information

Name of Spouse: 

Occupation: 

Is your spouse willing to come for counseling?   Yes
                                                                   No
Date of Marriage: 

Children and ages:
 

 

Have you seen a counselor in the last five years? Yes
                                                                      No
If so, who?    When 

Reason for seeking counseling? 

Why is it important that you get help now? (Maybe an event that has happened or that will happen in the last or next seven days) 



What do you want to accomplish by seeing a counselor?


Are you having thoughts of harming yourself?  Yes
                                                                 No
If so, what are your most recent thoughts?


Are you having thoughts of harming someone else? Yes
                                                                        No
If so, what are your most recent thoughts?


Is anyone threatening to harm you?  Yes
                                                    No
If so, whom most recently? 

If married, any pushing or hitting by spouse?   Yes
                                                                  No
If so, last occurrence? 

What happened?   

Are you or anyone else concerned about your use of alcohol or drugs?   Yes      No
If yes, what is the concern? 

Who can you talk to for emotional support? 

Are you willing to seek help beyond this counseling?
 Yes        No

To receive help from Agape Counseling, I am willing to pay:
Sliding Scale is:    $20,000 ($30,000 joint) or below - $5
                          $30,000 ($40,000 joint) or below - $10
 $5      or      $10