Step 1 of 119%HiddenToday's Date MM slash DD slash YYYY Your Name(Required) First Last GenderDate of Birth MM slash DD slash YYYY AgeReligionEmail(Required) Location City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code PRESENTING PROBLEM1. Your reason for contacting CSCM.2. How long have you or your loved one been experiencing this problem?3. Rate the intensity of this problem (1 being mild and 5 being most severe)MildModerateSevereVery SevereMost Severe4. How is this problem interfering with your daily functioning?5. How is this problem interfering with your spiritual relationship internally?6. How is this problem interfering with your relationship with the Heavenly Father?7. What are your current goals, or outcomes for counseling?8. How would your life be different if counseling is successful in helping you achieve your goals?EMOTIONAL HEALTH9. Please check all that apply to you now or in the last 30 days Angry/Irritable Have Special Powers Recurring Nightmares Anxiety Avoidance Can’t Be in Crowds Can’t Concentrate Depression Easily Startled Fatigue/No Energy Feeling Nervous Feeling Worthless Fearful Food or Eating Changes Grief and Loss Guilt Lack of Interest Hearing Things Helpless Hopeless Impulsive No Motivation Not Hungry No Need for Sleep Panic Attacks People Out to Get Me People Watching Me Poor Memory Prefer Being Alone Relationship Problems Restless Shame Sadness Seeing Things Self-Esteem Problems Self-Harm Sleep Changes Too Little Sleep Too Much Stress Substance Use Suicidal Thoughts Suspicious Thoughts of Dying Flashbacks InsomniaSelect All10. What type of issues in your life would disturb your sleep?11. Anything you would like to add?SELF-MEANING12. What do you consider your strengths?13. What do you consider your weakness?14. Do you remember the first time you were angry? Yes NoShare a little about it.15. What was the last thing that made you really angry? Share a little about it.16. Do you remember the first time you were hurt? If yes, share a little about it. Yes NoShare a little about it.17. What is your first memory in life?PERSONAL, FAMILY AND RELATIONSHIPS18. Where were you born?19. Were you raised there?20. Who was your primary caregiver?21. Was there a time when you had a primary caregiver who was not your biological caregiver? Share a little about it.22. Is your Father living? Yes No NAIf deceased what impact did his death have on you?23. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your father?1234524. Is your Mother living? Yes No NAIf deceased what impact did his death have on you?25. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your mother?1234526. How many brothers do you have?27. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your brother/s?1234528. How many sisters do you have?29. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your sister/s?1234530. Any half brothers or sisters? Yes NoPlease specify.Which biological parent did you share with them?31. Where are you in age order?32. On a scale of 1-5 with 5 being the highest, how would you rate your relationship with your siblings while growing up?1234533. On a scale of 1-5 with 5 being the highest, how would you rate your current relationship with your siblings?1234534. Do you feel there was a favored child in your family? Share a little about it.35. Did, or do you get along with that sibling(s)? Yes No NA36. Is there any known family history of mental illness or substance abuse? Yes No NA37. Were there any cultural and/or social issues that impacted your childhood? For instance, poverty, discrimination, oppression of any sort. Yes No NA38. Can you say that you grew up in a dysfunctional (broken/maladjusted) home? Yes No NANOTE: If questions 40-43 are too personal in nature to answer, you can choose to answer in session, if desired.39. Are you currently experiencing or has there been any problems with your family in the past (e.g., abuse, conflicts, stress, loss, etc)?(Required) Yes No I prefer not to sayPlease share a little about those problems. NOTE: you can choose to answer in session, if desired.40. Have you ever spent time in a prison or corrections facility? Yes No I prefer not to say41. Do you consider yourself to be:(Required) Heterosexual Homosexual Bisexual Other I prefer not to sayName your sexual orientation here:(Required)42. Has your sexual behavior ever led to involvement with the law?(Required) Yes No I prefer not to say43. Current marriage status?(Required) Married Divorced Separated Widowed Never Married44. How do you describe your relationship with your spouse?GoodFairPoorNAHow many marriages?How many divorces have you been involved in?Are you currently in a relationship?(Required) Yes NoHow long? Less than a month 1-6 months 1-3 years 3-5 years 6-10 years OtherHow do you describe your current relationship?GoodFairPoorNA45. Do you have children? Yes NoAre they all living? Yes NoSex and Ages of your ChildrenHow do you describe your relationship with your children?GoodFairPoorNA46. Any child custody or divorce issues? Yes No Not Sure47. Are you pregnant now? Yes No Not SureIf yes, when are you expecting?48. Are you at risk for HIV/AIDS/Sexually Transmitted Diseases? (Unsafe Sex / Using Needles?) Yes No NA49. Any food allergies?SUBSTANCE ADUSE / ADDICITONThere is therefore now no condemnation for those who are in Yahoshua. For the law of the Spirit of life has set you free in Yahushua from the law of sin and death. Romans 8:1-250. Are you a current or former tobacco user? Yes No NAWhat form(s) of tobacco have you used in the past?Have you been in a program to help you quit using tobacco in the last 30-days? Yes No NANOTE: If questions 52-54 are too personal in nature to answer, you can choose to answer in session, if desired.51. Would you or someone you know say you had a problem with alcohol use or addiction?(Required) Yes No I prefer not to say52. Would you or someone you know say you had a problem with pills or illegal drugs?(Required) Yes No I prefer not to say53. Is there a history in your family of addiction?(Required) Yes No I prefer not to sayPlease describe this in more detail. NOTE: you can choose to answer in session, if desired.54. Have you ever been to a self-help group?(Required) Yes No I prefer not to sayPlease share a little about it. NOTE: you can choose to answer in session, if desired.ABUSE HISTORYNOTE: If questions 56-57 are too personal in nature to answer, you can choose to answer in session, if desired.55. Have you been a victim of the following? Check all that apply.(Required) Verbal Physical Emotional Sexual Neglect Exploitation I prefer no to say56. Do you feel you are currently being abused? If yes, we will discuss during session.(Required) Yes No I prefer not to say57. Is there anyone in your life you have not forgiven?(Required) Yes No I prefer not to sayIf you could, would you forgive them?(Required) Yes No Not Sure58. Is there anyone in your life you need to ask them for forgiveness?(Required) Yes No I prefer not to sayDo you feel they will forgive you? Yes No Not SureEDUCATION, CURRENT WORK STATUS59. Highest Education Attainment? Elementary School Middle School High School Vocational Training Undergraduate Programs Master's Programs Professional Programs Doctoral Programs60. Are you a Veteran? Yes NoWhich Branch?What was your duty?61. Are you currently employed? Yes NoRetired? Yes NoWhat was your occupation?62. You ever had a problem holding a job? Yes No NA63. Do you have any job-related problems? Yes No NA64. School problems? Yes No NACOUNSELING HISTORY65. Are you currently, or within the last 60 days taken prescribed medication(s)? Yes No66. Have you previously been to a counselor or psychiatrist? Yes No67. During the last 6 months, have you thought of seriously hurting yourself or other people? Yes No68. Have you ever attempted suicide? Yes No69. Do you currently have plans to harm yourself? Yes No70. During the last month, how often have you gotten out of the house to do things other than go to work, and taking care of necessities?NeverSeldomOftenFrequentlyVIOLENCE AND TRAUMANOTE: If questions 72-78 are too personal in nature to answer, you can choose to answer in session, if desired.71. Were you ever a victim of a violent crime?(Required) Yes No I prefer not to sayHow old were you when it happened?72. Are you a victim of rape?(Required) Yes No I prefer not to sayHow old were you when it happened?73. When you were a child, were you ever touched or fondled in a sexually inappropriate manner?(Required) Yes No I prefer not to sayHow old were you?74. Were you ever made to touch/fondle someone in a sexual way?(Required) Yes No I prefer not to sayHow old were you?75. Were you ever forced to have sex with your spouse/significant other?(Required) Yes No I prefer not to say76. Has anyone stalked you, in other words, followed you or kept track of your activities, causing you to feel intimidated or concerned for your safety?(Required) Yes No I prefer not to say77. Are you currently afraid of someone harming you?(Required) Yes No I prefer not to sayMEDICAL/PAST MEDICAL/SURGICAL HISTORY78. Are you experiencing any medical problems now?(Required) Yes No I prefer not to sayPlease explain.79. List your past medications as best as you can.80. Are you taking any medications currently and what are the dosages for each?81. Have you ever been to a mental health professional before?(Required) Yes No I prefer not to sayWhat was the reason?(Required)82. Are you still going?(Required) Yes NoWhy did you leave?(Required)SPIRITUAL VIEWS83. What do your friends, family, spouse think of you as being Torah Observant?84. How would you describe the Ruach haQodesh (Holy Spirit)?85. “As I move towards Yah/Yahuah/Yahweh, He begins to rest in me.” What does this statement mean to you?86. What importance does your faith, belief, or spirituality have in your life?(Required)87. On a scale of 0 (not important at all) to 5 (extremely important), how you would rate the importance of faith, belief, or spirituality in your life?(Required)Very UnimportantUnimporantNeutralImportantVery Important88. Have your beliefs influenced you in how you handle stress?(Required) Yes No89. What role do your beliefs play in your health care decision making?90. Are you part of a spiritual or religious community?(Required) Yes NoShare a little about it such as the name of your religious community, how long you’ve been there, what you like or dislike about it, if you have plans to leave or remain there.91. Is this community supportive to you?(Required) Yes NoHow? Please explain.(Required)92. Is there a group of people you really love or who are important to you?(Required) Yes NoIf yes, share a little about it.93. Do you have spiritual beliefs or Bible verses that help you cope with stress? Yes No NAPlease share a little about this.94. On a scale of 1-5 where 5 is the highest how would you describe your relationship to Yahuah/Yahweh.1234595. On a scale of 1-5 where 5 is the highest where do you place your prayer life?1234596. On a scale of 1-5 where 5 is the highest how faithful are you to reading your Bible.1234597. What comes to mind when you think of Soul Care?98. Of which denomination(s) were you raised? If several list them all from earliest to latest.99. As an adult, how often do you attend services?NeverRarelyFairly OftenNot MuchRegulary100. When you were coming up as a child, did both parents attend church? Yes No Not SureAnything you would like to add?Thank you for taking the time to fill out these necessary questions. Your healing journey has begun.
