Faith-Oriented Depression Intake Form

Personal Information

Full Name Age Email Address Phone Number

Faith Background

Faith Tradition What role does faith play in your life?

Depression Symptoms

Describe your current feelings and symptoms How long have you been experiencing these symptoms? Have you identified any triggers? How would you rate the severity of your symptoms? Mild Moderate Severe How is this affecting your daily life?

Faith & Emotional Support

Are you involved in a faith community? Yes No Do you seek support from spiritual leaders or practices? Have faith practices helped you cope?

Goals & Expectations

What are your hopes or expectations for seeking help? Any additional information you'd like to share?