In this section, we'll ask you to provide some basic information about your current physical health. We ask for this information because sometimes physical symptoms can be an indicator of, or factor in, emotional distress. Additionally, understanding your current health can help us determine the best plan of care for you moving forward. Please answer the following questions as truthfully and accurately as you are able.
How would you describe your general health?
How often do you exercise?
Do you have any difficulties with sleeping?
How would you describe the food you typically eat each day?
How often do you drink coffee, tea, soft drinks, or other caffeinated beverages?
How often do you drink alcohol?
How often do you smoke tobacco?
Do you take any prescription medication?
Please list each medication you are taking along with the corresponding dosage.
Have you ever used prescription drugs for non-medical purposes?
Have you ever used, or been addicted to, any illegal drugs (including marijuana)?
Did any of the results from your last physical exam concern you or your physician?
In this section, we'll ask you to provide some information about your family history, upbringing, and personal history. Please answer the following questions as truthfully and accurately as possible.
Other than your parent(s), did you have any other significant role models in your life while growing up?
Are (or were) your parents divorced?
How would you describe your home atmosphere while growing up? Check all that apply.
Were you abused in your past?
To the best of your knowledge, was there substance abuse in your family?
Did you have any significant traumatic events as a child or have you ever had an extreme emotional reaction to a situation in your life?
How would you describe yourself? Check all that apply.
Have you ever had any counseling or psychotherapy?
In this section, we're looking to gather some information about your background as a Christian and your overall spiritual health. There are no right or wrong answers here, and your answers won't immediately qualify or disqualify you for care. We simply ask that you answer as truthfully as possible so that we can better determine how to care for you moving forward.
Would you consider yourself to be a Christian?
How often do you read the Bible?
Do you volunteer at Harvest?
In this final section, we would like to gather some additional information about the issue you are facing, why you chose to seek counseling, and what steps you've taken so far to address the problem. Again, there are no right or wrong answers here, but by answering truthfully, you'll help us learn how to better address your issue and help care for you.