Contact Us HOME

Initial Session Information

Name: 
Address: 
City, State, Zip: 
Phone: 
Cell Phone: 
Sex:  Male  Female
Birthdate: 
Marital Status:  Single Married Separated Divorced Widowed
Name of Spouse (if married): 
Occupation: 
Is your spouse willing to come for counseling?  Yes  No
Date of Marrage: 
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.) 
Are you having thoughts of harming yourself?  Yes  No
If so, what are your most recent thoughts? 
Are you havaing 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 occurance? 
Are you or anyone else concered 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
Counseling fee is $60 ($50 church attendees).
Payment is due at the time of service. A receipt will be given upon request to submit to insurance.
Do you need to be considered for the sliding pay scale?  Yes  No
          Sliding Scale is:  Income of $20,000 ($30,000 joint) or below - $5
                                        Income of $30,000 ($40,000 joint) or below - $10
Proof of income (last year's tax return or last month's pay stub) is required for sliding scale.
To receive help from Agape Counseling, I am able to pay:  $60 $50 $10 $5