Faith-Based Family Counseling Intake Form
Family Information
Family Name
Date
Address
Phone
Email
Emergency Contact (Name & Phone)
Household Members
List all household members (Name, DOB, Relationship):
Faith Background
Faith/Religious Affiliation
Spiritual Leader/Church Contact
How would you describe your family’s involvement in your faith or faith community?
Presenting Concerns
What brings your family to counseling?
What are your goals for counseling?
Previous Support
Has your family participated in counseling or support services before?
Are you currently working with any other professionals (medical, legal, etc.)?
Additional Information
Anything else you would like your counselor to know?