Intake Form

1
Which service are you interested in?* This field is required.
Professional Counseling
Groups
Coaching
Organizational Consulting/Equipping
2
Your Info:* This field is required.Tell us more about you!
Your Name
Please enter your email
Please enter your phone
Your Church/Organization's Name
Your role at the Church/Organization
Please describe what equipping /consulting needs your organization has
3
Which type of counseling are you interested in?* This field is required.
Individual Counseling
Counseling for a Child/Teen
Marriage/Couples Counseling
Pre-Marital Counseling
4
Current Group Offerings:
5
Please select the group that you are interested in:* This field is required.
Please Select
Please Select
Making Sense of Your Worth
Sexual Integrity
6
Your Info* This field is required.
Please enter your first and last name
Please enter your age
Please enter your phone #
Please enter your email
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Married
Single
Engaged
Divorced
Widowed
Marital Status
7
Your Partner's Info* This field is required.We will contact your partner as well when pairing you with a counselor.
Please enter their first and last name
Please enter their age
Please enter their your phone #
Please enter their email
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Married
Single
Engaged
Divorced
Widowed
Marital Status
8
Are you engaged?* This field is required.
YESNO
9
What is your wedding date?
Date
Month
Day
Year
10
Parent Info* This field is required.Please include all parent/caregivers who have rights to give consent for services. Both parents will be notified when your child has been paired with services.
Parent #1 First & Last Name
Parent #2 First & Last Name
Parent #1 Phone Number
Parent #2 Phone Number
Parent #1 Email
Parent #2 Email
11
Child's Info* This field is required.
Child's First & Last Name
Child's Age
Child's Gender
Please Select
Please Select
Yes, they want to do counseling.
No, they do not want to do counseling.
I am encouraging counseling and they are open to it.
Is Child Requesting Counseling?
Has Child Received Counseling Before? If yes, briefly describe.
12
Client Name* This field is required.
First Name
Last Name
13
Gender* This field is required.
Male
Female
N/A
14
Marital Status* This field is required.
Single
Married
Divorced
Widowed
Remarried
15
Date of Birth* This field is required.
Date
Month
Day
Year
16
Phone Number* This field is required.
Please enter a valid phone number.
17
Email* This field is required.
example@example.com
18
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Karis House uses email as the primary method of communication. Is it ok for us to email you?* This field is required.
Please Select
Please Select
Yes
No
20
What is the best way to communicate with you?
Phone call - but do NOT leave a voicemail
Phone call - you may leave a voicemail
21
Do you attend a local church?* This field is required.
Please Select
Please Select
Yes
No
22
Which church do you attend?* This field is required.
The Journey - West County
Refresh Community Church (formerly The Journey - Hanley Road)
The Journey - Tower Grove
Other
23
Are you seeing (or have you seen in the last year) a counselor, psychologist, psychiatrist or other mental health professional?* This field is required.
YESNO
24
Please provide their name(s) and a brief description of what you see/saw them for:
Huge
Large
Normal
Small
Ok
Ok
25
Were you referred to Karis House? If so, by who?
26
Is there a specific counselor/coach that you have been referred to or are hoping to see? If so, please write their name here.
27
Please briefly describe why you are seeking counseling or coaching at this time:* This field is required.
28
Please briefly describe why you are seeking counseling for your child at this time:* This field is required.
29
Are any of these present?Please check all that apply.
Depression
Anxiety
Panic Attacks
Thoughts of Suicide
Sexual Issues
Eating Disorder
Substance Abuse
Marriage Issues
Children Issues
Victim of Abuse (Past)
Victim of Abuse (Current)
Spiritual Issues
Housing Issues
Vocational Issues
Financial Issues
Family Issues
30
Please rate the severity of your depression:(in the last 7 days)
Very Low
Mild
Moderate
Severe
Worst I Have Ever Experienced
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Very Low
Mild
Moderate
Severe
Worst I Have Ever Experienced
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31
Please describe your depressive symptoms:
Huge
Large
Normal
Small
Ok
Ok
32
Please rate the level of your anxiety:(in the last 7 days)
Very Low
Mild
Moderate
Severe
Worst I Have Ever Experienced
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Very Low
Mild
Moderate
Severe
Worst I Have Ever Experienced
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
33
Please describe your anxiety symptoms:
Huge
Large
Normal
Small
Ok
Ok
34
Tell us more about your panic attacks:
How often do they happen?
When was the last time you had a panic attack?
35
Tell us more about the eating disorder:
Please Select
Please Select
Yes
No
Have you been diagnosed with an eating disorder by a doctor or mental health professional?
Have you received treatment (past or present)? If so, please describe.
36
In the last month, have you wished you were dead or wished you could go to sleep and not wake up?
YESNO
37
In the last month, have you had any actual thoughts of killing yourself?
YESNO
38
In the last month, have you been thinking about how you might do this?
YESNO
39
In the last month, have you had these thoughts and had some intention of acting on them?
YESNO
40
In the last month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
YESNO
41
In the last month, have you ever done anything, started to do anything, or prepared to do anything to end your life?
YESNO
42
In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life?
YESNO
43
Please provide your availability for sessions:* This field is required.Please check all that apply
Monday Mornings (9a - noon)
Monday Afternoons (1p - 3p)
Monday Evenings (4p - 9p)
Tuesday Mornings (9a - noon)
Tuesday Afternoons (1p - 3p)
Tuesday Evenings (4p - 9p)
Wednesday Mornings (9a - noon)
Wednesday Afternoons (1p - 3p)
Wednesday Evenings (4p - 9p)
Thursday Mornings (9a - noon)
Thursday Afternoons (1p - 3p)
Thursday Evenings (4p - 9p)
Friday Mornings (9a - noon)
Friday Afternoons (1p - 3p)
44
Please select your preferred location for services:* This field is required.We cannot guarantee you will be placed at your preferred location, but will do our best to accommodate.
The Journey - West County (Ballwin, MO)
Refresh Community Church (University City, MO)
Virtual Counseling (MO residents only)
No preference
45
Are you receiving care from a deacon, elder, or pastor & would like them to be able to communicate with your counselor?
YESNO
46
Anything else you would like us to know about you or your situation?
Should be Empty: