BNJ HOLISTIC COUNSELLING & WELLNESS CENTRE

ADULT INTAKE FORM

The purpose of this form is to help us understand you better. Fill this form as honestly as possible.

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Name
Sex?
Do you have any religious affiliations?
Have you had any counselling or therapy in the past?
Indicate which applies?
How old are you?
Indicate which applies?
Do you have any worries or problems about intimacy?
Do you drink alcohol?
How often do you drink?
How would you rate your current financial status?
How would you rate your current eating habit?
Are you currently experiencing overwhelming sadness, grief or depression?
Over the past 2 weeks, how often have you been experiencing any of the following problems: Little interest or pleasure in doing things?
Over the past 2 weeks, how often have you experienced any of the following: Moving or speaking so slowly that it was noticed by others or, becoming fidgety or restless, moving more than usual?
Over the past 2 weeks, how often have you experienced any of the following problems: Feeling down, depressed or hopeless?
Over the past 2 weeks, how often have you experienced any of the following problem: Trouble falling asleep, staying asleep or sleeping too much
Over the past 2 weeks, how often have you experienced any of the following problem: Feeling tired or having little energy?
Over the past 2 weeks, how often have you experienced any of the following problem: Poor appetite or over-eating?
Over the past 2 weeks, how often have you experienced any of the following problem: Feeling bad about yourself or that you are a failure or have let yourself down or your family down?
Over the past 2 weeks, how often have you experienced any of the following problem: Trouble concentrating, reading or watching television?
Over the past 2 weeks, how often have you experienced any of the following problem: Thoughts that you would be better off dead or hurting yourself in some way?
Over the past 2 weeks, how often have you experienced any of the following problem: How difficult have these problems made it for you to do work, take care of things at home or get along with other people?
Do you ever have suicide thoughts?
When was the last time you thought about suicide?
Are you currently experiencing anxiety, panic attacks or any phobias?
Are you currently taking any medications?
Are you currently experiencing any chronic pain?
How would you rate your current sleeping habits?
Are you being abused or bullied by anyone?
What type of counselling are you looking for?
Do you currently live with your partner?
Is domestic violence currently an issue in your relationship?
Will your partner be part of the sessions?
Do you prefer to work with a younger or older counsellor?
Do you prefer to work with a more liberal or conservative counsellor?
Do you prefer to work with a religious Christian counsellor?
How do you prefer to communicate with your counsellor?
How did you get to know about BNJ Holistic Counselling & Wellness Center?
Read and sign our Consent Forms here: https://bnjholisticcounselling.com/consent-forms/
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Name
**SIGN YOUR NAME. THIS SHALL CONSTITUTE YOUR ELECTRONIC SIGNATURE**