Client Application Form for the Partnership for Pastoral Counseling

Name:  

Address:   
Address2: 
City:          State:    Zip:       County of Residence:

Social Security #:       Home Phone:       Work Phone:

May We Contact Your Home Phone & Leave A Message?   Yes         No

Gender (M/F):       Ethnicity (optional):
Age Range (select one): 18 - 25     26 - 35     36 - 45     46 - 55     56 - 65     66 - 75     76 - 85     86+

Marital Status (select one): Single    Married    Separated    Divorced    Widowed    Significant Other
Number of people in your household:       How many are under 18 years old:
Annual Gross Household Income: including all deductions for taxes, retirement, and insurance
Other Income:      Child Support:               Alimony:
                            Disability:                      Retirement:
                            Public Assistance:          Other:   

Spouse's Name:
Spouse's Address (if different):
Spouse's Employment:

Your Employment and/or School: Employment   Attending School:
Your Church Affiliation (if any):   Pastor's Name:
Your preference (if any) for: Male or     Female Pastoral Counselor
I also prefer a pastoral counselor who (optional, fill in blank):
What is the difficulty that caused you to seek counseling?

Please rate your present capacity to respond to this difficulty:
(1=Very stressed with little ability to cope, low capacity; 10= Not stressed about situation, coping very well)
1      2      3      4      5      6      7      8      9      10
(Low)                                                                                                                     (High)

Please rate your present overall life satisfaction:
1      2      3      4      5      6      7      8      9      10
(Low)                                                                                                                     (High)

Please rate your present level of distress:
1      2      3      4      5      6      7      8      9      10
(Low)                                                                                                                     (High)

How important is it to you that your counselor takes seriously your religious faith perspective?
1      2      3      4      5      6      7      8      9      10
(Not Important)                                                                                            (Very Important)

Name of Insurance Company:
Policyholder (circle one): Self       Spouse       Parent       Name of Policyholder:
Policy #: Group Policy #:
Deductible for Mental Health Benefits:       Per Session Benefits:
Is there other insurance? Yes       No       Other Company's Name:
                                                                           Policy Number:

If you have had counseling in the past, please list the agency where you received help (optional):
Are there any special circumstances you wish to make us aware of?

You will be sent a letter regarding the status of your application to the above address unless otherwise noted. During your counseling the Executive Director and Board Treasurer will confidentially know your identity. Do you understand and agree to this arrangement?
Yes       No

I have read and understood the Client Guidelines. Yes      No