On-line Intake
Counseling Record


Live Help Software

(When you complete this form, there will be additional instructions including a Christ-based Counseling Healing and Wholeness Assessment, and The Process of Being Made Whole orientation to Christ-based Counseling). These should be completed before your sessions begin.  If you have any problems email: Counseling Support or use the online button for immediate support.


Contact and General Information

Counselees Name: Age: HPhone: WPhone

Address Sex: M/F   No. of Dependents

City: State:    Zip   Marital Status (Div/Sing/Sep/Marr):
Email address:                                                  Years Married, if applicable:

Employment and Education Information 

Place of employment (if applicable): Yrs Employed: 
Position:  Highest Education   H.S. or GED 1-4 College Graduate

Type of Counseling

Marital Pre-Marital Substance Ab. Co-Dependency Emotional Employment Social
Loss of Life Parent-child Moral Remarriage Divorce Financial Other


Are you currently on any medication   (if so)  is the medication for/or related to the condition you are seeking counseling 
Have you sought the assistance of any other counselor, psychologist, or psychiatrist concerning this matter

Briefly discuss the condition that encouraged you to seek counseling (include when the condition began, and other important events):

During this period, how would you describe your response(s)?

Guilt Grief Sorrow Despair Fear Anger Hatred
Rage Relief Helplessness Confusion Heart ache Betrayed Self-pity
Don't care Given-up Joy Loneliness Desparation Embarrassed Vindictive
Frustration Up and down Worthless Worried

Are there any persons who are having a positive influence on this situation/circumstance (if so, please explain)

   Are there any persons who are having a negative influence on this situation/circumstance? (if so, please explain)


What is your desired objective of seeking counseling?   


Do you know of any reason why you cannot reach the desired objective?

I agree that I have not been coerced, manipulated, forced or otherwise threatened to make decisions according to my faith.  I understand and agree that decision subsequent decisions are fully my personal choice.  I am therefore, fully accountable and completely responsible for any decision during or after any or all counseling sessions are concluded. I recognize that because of God's love, he has given me the liberty to make decisions that may or may not agree with His will.  While I have sought counsel from NACCBC, Dr. DavidSon, and/or those working with him, I recognize and exercise my right to make the decision I desire (considering all issues directly or indirectly related to the issues stated above). 


NOTE: You may elect to submit this form electronically.  If so, you are agreeing and affirming all stated or indicated on this form.
using the SUBMIT button:

Check all of the information and be sure that it is correct: Reset your entries by clicking this button: