Holston Center
for
Wellbeing
Kathy T. Heustess, MAR, MSW, LCSW Conference Pastoral Counselor
Client Confidential Intake Information Please carefully respond to questions
Name: ________________________________
Date: ______________________________
Home Address: _________________________
Date of Birth: _______________________
Email address: __________________________
Cell: ______________________________
Marital Status:
Single
Married
Divorced
Separated
Widowed
Employment: __________________________________________________________________ Referred by: ___________________________________________________________________ Permission to contact referral source to acknowledge that you followed up on your appointment? Yes
No
________________________________ Signature please
Religious affiliation: _____________________________ Active? Yes
Family – Please check those living in your home.
No
Please mark X those who are deceased.
Current Spouse/partner _______________________
Age ____ Father _________________
Age ___
Date of Marriage ____________________________
Mother _________________
Age ___
Children ___________________________________
Age ____ Siblings ________________
Age ___
__________________________________________
Age ____
______________________
Age ___
__________________________________________
Age ____
______________________
Age ___
__________________________________________
Age ____
______________________
Age ___
Others ____________________________________
Age ____
______________________
Age ___
__________________________________________
Age ____
______________________
Age ___
Prior Marriage(s) If you have been previously married, please give the following dates and information: First marriage from ________ to _________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Second marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Third marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________
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