Faith-Based Trauma Counseling Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact
Name
Relationship
Phone Number
Faith Background
Religious Affiliation
Church/Community Involvement
Current Spiritual Support
Presenting Issues
Describe the Trauma or Difficult Experiences
How has this experience affected your life?
Current Symptoms or Challenges
Goals for Counseling
What do you hope to achieve through faith-based counseling?