Confidential Intake Form

Confidential Intake Form

GCL Ministries, Inc.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
In addition to phone calls, email is the preferred means of ongoing communication in order to send information, forms, documents, and to schedule appointments. Please indicate any restrictions regarding the means to communicate with you.*
Birthdate*

MonthDayYear
Date
Age*
Briefly describe why you're seeking help and what you hope to accomplish.*
Family Information
If you have ever been married, please provide for each time: the marriage date, length of time, and spouse's first name.*
If you have children, please provide the name, gender, age, and whether or not they are living with you.*
Please provide the following regarding parents, stepparents or guardians: Name, Relationship, Age, Living with you?*
If you have siblings, please provide the name, gender, age, and whether or not they are living with you.*

Counseling/Coaching Information
Who referred you to GCL Ministries, Inc?*
Are you currently participating in any other counseling, coaching or care services?*
If you have been involved in previous counseling, please provide for each time: the beginning date, the length of time, and who provided the counseling:*

Church Information
What church do you attend, and for how long have you been there?*
Church Denomination:*
Church Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Church Phone Number*
Please enter a valid phone number.
Are you involved in any type of ministry within or outside of your church?*
If yes, what areas of service?*
Pastor's Name*
Do you give permission to your counselor/coach to consult with your Pastor?*
If you are under the age of 18, do you give permission to your counselor/coach to consult with your parents or legal guardians?*
Do you have any other questions about counseling?*
All information completed on this form is provided by myself and to my knowledge is true, as to reflecting my interpretation to the information requested. (Please input your name to sign and date.)*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

	Daily	Few Days a Week	Weekly	Bimonthly	Monthly	Few Times a Year	Never
Personal Prayer
Personal Bible Reading
Small Fellowship Group Involving Prayer and Bible Study
Same Sex Growth/Accountability Groups
Social Gatherings with Close Christian Friends
Read or Listen to Material Regarding Your Christian Growth
Attend Classes on Christian Growth

Family Information