Adult Intake Form 2025 "*" indicates required fields Step 1 of 14 7% LinkedInThis field is for validation purposes and should be left unchanged.1 - Client InformationLegal Name* Prefix Mr.Mrs.MissMs.Dr.Rev. First Last Name you prefer (nickname)Sex* Male Female Age*Please enter a number from 1 to 125.Date of Birth* Month Day Year How did you hear about Blue Fire Legacy?*If referred by a friend, please tell us who. 2 - Contact InformationAddress* Street Address Suite/Apt # City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe May we send mail here?* Yes No What country do you serve if outside of the United States?Mailing Address (If different from above) Street Address Suite / Apt # City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Mobile Phone*Home PhoneWork PhoneWhatsApp NumberSelect any phone lines that we may leave voice messages on.* Mobile Phone Home Phone Work Phone WhatsApp Select AllEmail* Enter Email Confirm Email 3 - Emergency ContactIn case of an emergency I give you permission to contact the following on my behalf.Name(s)*Relationship(s) to you*Contact Phone Number*Consent*In case of an emergency, I give you permission to contact the following emergency contact(s) listed on my behalf. I Agree 4 - EmploymentAre you currently employed? Yes Current Employer*Length of employment*Occupation*Avg hours worked per week*Are you bi-vocational? Yes Secondary Employer*Length of employment*Occupation*Avg hours worked per week*Qualifications to receive services:*I qualify for services because I am one of the following (please check all that apply). I am a pastor. I am a pastor's spouse. I am a pastor's child. I am a missionary. I am a missionary's spouse. I am a missionary's child. I am currently training to enter vocational ministry. I have been exited from ministry in the last 5 years. My spouse has been exited from ministry in the last 5 years. My parent(s) were exited from ministry in the last 5 years. Personal invitation from a BFL counselor. Church Denomination*Please share your church's denomination.Missions Affiliation*Please share the mission organization you are affiliated with. 5 - EducationAre you currently in school? Yes School Name(s) and Location(s)Years / Degrees / Majors Completed:Comments about education: 6 - The Nature of Your Issues and GoalsWhy are you seeking assistance through Blue Fire Legacy?*What do you want to address during our time together?Help us help you*Based on your current need for pastoral care and counsel, what are your top 2 goals for our time together. (You may add a 3rd if desired.) In other words, how would you complete these sentences? “I’ll know our time of working together is complete when__________________.” “I’ll know our time together was successful when _______________________.” “I’ll know I’ve completed the work I need to do when _____________________.”Level of Distress*Indicate how distressed you are by selecting the appropriate number below. (1 = Very Little Distress, 6 = High Stress, 10 = Extreme Distress) 1 2 3 4 5 6 7 8 9 10 7 - Relationships: EngagedAre you currently Engaged? Yes When did you get Engaged?*Are you experiencing distress or difficulty within your engagement?(ie: the context of this relationship or any undesired status changes or lingering issues you feel need to be addressed before marriage)MarriageAre you currently Married? Yes When did you get Married?*Are you experiencing distress or difficulty within your marriage?(ie: the context of this relationship or any undesired status changes)Any prior marriages? Yes When were your previous marriages?*Widow or WidowerAre you currently a widow or widower? Yes When did you lose your spouse?*Are you experiencing distress or difficulty with the loss of your spouse?(ie: intense grief, depression, other symptoms)ChildrenDo you have any Children? Yes Child(ren) First name(s) and Age(s)*Have you ever lost a child or suffered a miscarriage? Yes If Yes, then list when you experienced this.*Are you experiencing distress or difficulty within you and your child's relationship?(ie: the context of this relationship or any undesired status changes) 8 - Previous or Current CounselingAre you currently Receiving Counseling? Yes No Who are you currently meeting with? Counselor Pastor Church Ministry Have you received counseling in the past? Yes No List any previous counseling, psychiatric treatment, or residential / in-patient care you have received. Use the Additional Notes box for additional space if needed. If you are currently receiving care from another counselor, please explain why you are also seeking care from Blue Fire Legacy. Do you intend to continue or terminate services with the other provider if you choose to continue engaging the services of Blue Fire Legacy? If choosing to continue simultaneously with both, please explain why.Types of counseling:Please check the types of counseling you are currently receiving or have had in the past. CBT DBT EFT (Tapping) EFT (Emotionally Focused Therapy) EMDR Hypnosis IFS (Internal Family Systems) Murray Method Rapid Rewire Reiki Splankna Talk Therapy Theophostics Other: Other:I plan to continue/terminate services with another counselor while seeking care with Blue Fire Legacy. Continue Terminate Explanation for receiving simultaneous services from multiple counselors.Prior and/or current therapistTherapist 1LocationDatesReasonOutcomeTherapist 2LocationDatesReasonOutcomeAdditional NotesWe offer Christian based pastoral counseling rather than providing clinical mental health care. If you are used to just telling your story over and over, please know we will encourage you to do things differently during your time with us. Is there anything you would like us to know about any previous counseling you have done? 9 - Mental HealthPlease select any of the following problems that pertain to you and/or your family.I understand that this information is used as reference, however, I am not being treated by Blue Fire Legacy for clinical mental health issues.* I understand ADHDHave YOU been diagnosed with ADHD? Yes Diagnosed as:How long have you had your diagnosis?If not diagnosed, do you have suspicions that you struggle with ADHD? Yes Has anyone in your FAMILY been diagnosed with ADHD? Yes Relationship to you (mother/father, grandparent etc.)Ambition (In Excess or Lack Of)Do YOU feel you have an excess of Ambition or have little to no Ambition at all? Yes I feel that I have Excess of ambition Lack of ambition Does a FAMILY MEMBER have an excess of Ambition or have little to no Ambition at all? Yes Relationship to you (mother/father, grandparent etc.)Anger / Temper (In Excess / Lack Of)Do YOU feel you are quickly angered or don't experience anger? I struggle to acknowledge and process anger, so I work to avoid it completely. I experience and express anger at a moderate intensity with the severity depending on the situation. I am quickly angered or only experience anger in an extremely volatile way. Describe frequencyDoes a FAMILY MEMBER GET quickly angered or never experience anger? Quickly angered Doesn't express anger Relationship to you (mother/father, grandparent etc.)AnxietyHave YOU been diagnosed with or experience Anxiety which impairs your quality of life? Yes When were you diagnosed?Describe frequencyHas a FAMILY MEMBER been diagnosed with or experience Anxiety which impairs their quality of life? Yes Relationship to you (mother/father, grandparent etc.)Autism SpectrumHave YOU been diagnosed on the Autism Spectrum? Yes When were you diagnosed?Please describe the severityCommunicationDo YOU feel YOU struggle with Communication or Communicating YOUR Feelings? Yes Give a brief exampleIs this situationally driven? Yes When is communication impaired?Does a FAMILY MEMBER struggle to communicate ideas or emotions? Yes Relationship to you (mother/father, grandparent etc.)Compulsivity / Impulsive BehaviorHave YOU ever exhibited signs of Compulsive or Impulsive behavior? Yes Describe frequencyWhat type of behavior do you exhibit?Does a FAMILY MEMBER have compulsive or impulsive behaviors? Yes Relationship to you (mother/father, grandparent etc.)DepressionHave YOU ever been diagnosed with Depression or experience(d) Depression to the extent that it negatively impacts your quality of life? Yes When were you diagnosed?Describe frequencyDescribe the severityHas a FAMILY MEMBER ever been diagnosed with Depression or experience(d) Depression to the extent that it negatively impacts their quality of life? Yes Relationship to you (mother/father, grandparent etc.)Emotional AwarenessDo YOU feel that you lack Emotional Awareness? Yes Please describeDescribe frequencyDescribe the severityDo you feel a FAMILY MEMBER lacks Emotional Awareness? Yes Relationship to you (mother/father, grandparent etc.)Emotional VolatilityDo YOU feel, or have you been told, that you experience Emotional Volatility (really high highs and really low lows with rapid expression in words or behavior)? Yes Please describeDo you have a FAMILY MEMBER that experiences Emotional Volatility? Yes Relationship to you (mother/father, grandparent etc.)FearsDo YOU feel that you experience overwhelming or pervasive Fear? Yes Please describeDo you have a FAMILY MEMBER that experiences overwhelming or pervasive Fear? Yes Relationship to you (mother/father, grandparent etc.)GriefDo YOU feel that you experience overwhelming Grief or struggle to experience Grief? Struggle to experience grief Experience overwhelming grief Please describeI feel I don't know how to grieve or have permission to grieve. Yes Do you have any loss that you have not completed grieving? Yes Describe past events causing unresolved griefGuiltDo YOU feel that you experience intense or overwhelming Guilt? Yes Please describeDoes a FAMILY MEMBER experience intense or overwhelming Guilt? Yes Relationship to you (mother/father, grandparent etc.)HopelessnessDo YOU experience prolonged feelings of Hopelessness? Yes Please describeHas a FAMILY MEMBER experienced prolonged feelings of Hopelessness? Yes Relationship to you (mother/father, grandparent etc.)Inferiority Feelings/Imposter SyndromeDo YOU frequently experience feelings of Inferiority or Imposter Syndrome? Yes Please describeHas a FAMILY MEMBER experienced frequent feelings of Inferiority or Imposter Syndrome? Yes Relationship to you (mother/father, grandparent etc.)LonelinessHave YOU experienced prolonged feelings of Loneliness? Yes Please describeHas a FAMILY MEMBER experienced prolonged feelings of Loneliness? Yes Relationship to you (mother/father, grandparent etc.)Loss of ControlDo YOU frequently experience feelings of Losing Control? Yes Please describeHas a FAMILY MEMBER experienced frequent feelings of Losing Control? Yes Relationship to you (mother/father, grandparent etc.)Making Decisions/Decision ParalysisDo YOU frequently experience difficulty making Decisions? Yes Please describeDoes a FAMILY MEMBER frequently experience difficulty making Decisions? Yes Relationship to you (mother/father, grandparent etc.)MemoryHave YOU ever experienced Memory Issues? Yes Please describeDo you have a specific diagnosis for memory loss? Yes No When were you diagnosed?What was the diagnosis?Does a FAMILY MEMBER experience Memory Issues? Yes Relationship to you (mother/father, grandparent etc.)NervousnessDo YOU ever experience frequent or persistent Nervousness? Yes Please describeDoes a FAMILY MEMBER experience frequent or persistent Nervousness? Yes Relationship to you (mother/father, grandparent etc.)PanicDo YOU experience intense or overwhelming Panic? Yes Describe the intensityDescribe the frequencyDescribe the context in which you experience overwhelming panicDoes a FAMILY MEMBER experience intense or overwhelming Panic? Yes Relationship to you (mother/father, grandparent etc.)Racing ThoughtsDo YOU experience Racing Thoughts frequently or regularly? Yes Describe the intensityDescribe the frequencyDoes a FAMILY MEMBER experience Racing Thoughts frequently or regularly? Yes Relationship to you (mother/father, grandparent etc.)Self-ControlDo YOU experience a Loss of Self Control on a regular basis? Yes Describe the intensityDescribe the frequencyDescribe the context(s) where you struggle with self-control.Does a FAMILY MEMBER experience a Loss of Self Control on a regular basis? Yes Relationship to you (mother/father, grandparent etc.)ShynessDo YOU frequently experience the feeling of Shyness? Yes Describe the intensityDescribe the frequencyDoes a FAMILY MEMBER frequently experience Shyness? Yes Relationship to you (mother/father, grandparent etc.)StressDo YOU constantly experience the feeling of being Stressed Out? Yes Please describeDoes a FAMILY MEMBER have a pattern of feeling Stressed Out? Yes Relationship to you (mother/father, grandparent etc.)Suicidal ThoughtsDo YOU experience Suicidal Thoughts? Yes Describe the intensityDescribe the frequencyDo you have a plan? Yes No Do you have the means? Yes No Has a FAMILY MEMBER experienced Suicidal Thoughts? Yes Relationship to you (mother/father, grandparent etc.)UnhappinessDo YOU experience Unhappiness frequently? Yes Please describeDoes a FAMILY MEMBER experience Unhappiness frequently? Yes Relationship to you (mother/father, grandparent etc.)Unwanted ThoughtsDo YOU experience Unwanted Thoughts frequently? Yes Please describeDoes a FAMILY MEMBER experience Unwanted Thoughts frequently? Yes Relationship to you (mother/father, grandparent etc.) 10 - Physical HealthPlease select any of the following problems that pertain to you and/or your family. I understand that this information is used as reference, however, I am not being treated by Blue Fire Legacy for physical health issues.* I understand AbortionHave YOU ever had an Abortion? Yes Please provide more information including the number of abortions, dates, and anything else you want us to know.Has a FAMILY MEMBER ever had an Abortion? Yes Relationship to you (mother/father, grandparent etc.)Addiction (Alcohol / Substance Abuse / Gambling / Sexual)Have YOU ever experienced, or are you currently experiencing, an Addiction? Yes If Yes, then please list the Addiction you struggle(d) with and indicate whether or not you have adequately addressed this Addiction.*How often do you engage in the specific Addiction behaviors?When is the last time you used your vice of choice?Has a FAMILY MEMBER ever experienced an Addiction? Yes Relationship to you (mother/father, grandparent etc.)If Yes, then please list the Addiction your family member struggles with.Bad DreamsDo YOU experience pervasive Bad Dreams or Intense Nightmares? Yes Please describe frequency and distress levelIf you have a recurring dream, please provide a brief narrative of the dream here.Does a FAMILY MEMBER experience pervasive Bad Dreams or Intense Nightmares? Yes Relationship to you (mother/father, grandparent etc.)Chronic IllnessHave YOU been diagnosed with a Chronic Illness? Yes Please describeWhen were you diagnosed?Has a FAMILY MEMBER been diagnosed with a Chronic Illness? Yes Relationship to you (mother/father, grandparent etc.)When?(Please let us know if this is Past, Present, or Past and Present)Eating IssuesHave YOU been diagnosed with, or struggle with, Disordered Eating? Yes Describe specific behaviors and frequency of occurrenceHas a FAMILY MEMBER been diagnosed with, or struggle with, Disordered Eating? Yes Relationship to you (mother/father, grandparent etc.)Physical LimitationsHave YOU been diagnosed with, or are currently experiencing, Long-term Physical Limitations? Yes Please describeHas a FAMILY MEMBER been diagnosed with, or are currently experiencing, Long-term Physical Limitations? Yes Relationship to you (mother/father, grandparent etc.)PregnancyAre YOU/your wife currently Pregnant? Yes When are you due?Have YOU/your wife had difficult Pregnancies in the past? Yes When did you experience these?Have your FAMILY MEMBERS had difficult Pregnancies in past generations? Yes Relationship to you (mother, aunt, grandmother etc.)Severe / Major InjuryHave YOU ever experienced a Severe/Major Injury? Yes When did this occur?Please describeHave any of your FAMILY MEMBERS ever experienced a Severe/Major Injury? Yes Relationship to you (mother/father, grandparent etc.)Sleeplessness / InsomniaDo YOU experience Sleeplessness / Insomnia? Yes Describe frequencyDescribe a typical night's sleep patternDoes a FAMILY MEMBER experience Sleeplessness / Insomnia? Yes Relationship to you (mother/father, grandparent etc.)Terminal IllnessHave YOU been diagnosed with a Terminal Illness? Yes Please describeHas a FAMILY MEMBER been diagnosed with a Terminal Illness? Yes Relationship to you (mother/father, grandparent etc.) 11 - Life EventsPlease select any of the following problems that pertain to you and/or your family. I recognize that life events can have a cumulative impact on my wellbeing.* I understand Difficult or Regretted Career ChoicesHave YOU regretted your Career Choices? Yes Please describeHave any of your FAMILY MEMBERS regretted their Career Choices? Yes Relationship to you (mother/father, grandparent etc.)DisasterHave YOU experienced a Disaster which currently impacts your quality of life (in any area: emotional/physical/spiritual)? Yes Please describeHave any of your FAMILY MEMBERS experienced a Disaster which currently impacts their quality of life (in any area: emotional/physical/spiritual)? Yes Relationship to you (mother/father, grandparent etc.)Job StrugglesAre YOU currently experiencing Job Struggles? Yes Please describeHas anyone in your FAMILY experienced a pattern of Job Struggles? Yes Relationship to you (mother/father, grandparent etc.)Legal MattersAre YOU involved in any Legal Matters which impact your emotional wellbeing? Yes Please describeIs anyone in your FAMILY involved in any Legal Matters which are impacting their emotional wellbeing? Yes Relationship to you (mother/father, grandparent etc.)Lodge Involvement (Eagles, Freemasons, etc.)Have YOU ever been involved in any Lodges (Eagles, Freemasons, etc.) or Secret Societies? Yes When?(Please let us know if this is Past, Present, or Past and Present)Please specify YOUR involvement Ancient Arabic Order or the Nobles of the Mystic Shrine Ancient Order of Druids Ancient Order of the Foresters Blue Lodge of Freemasonry Buffaloes Lodge Daughters of the Eastern Star Eagles Lodge Eastern Star Elks Lodge The Grange International Order of DeMolay International Order of Job's Daughters International Order of Oddfellows International Order of Rainbow for Girls Knights of Columbus Knights of Malta Knights of Pythias Knights Templar Ku Klux Klan Lions Club Moose Lodge Mystic Order of the Veiled Prophets of the Enchanted Realm The Orange Order Order of Amaranth Order of the Red Cross Prince Hall Masonry Riders of the Red Robe Rotary International Scottish Rite of Freemasonry Shriners White Shrine of Jerusalem Woodmen of the World York Rite of Freemasonry Other... Other Lodge/Society Involvement for YOU?Has anyone in your FAMILY ever been involved in any Lodges (Eagles, Freemasons, etc.) or Secret Societies? Yes Relationship to you (mother/father, grandparent etc.)Please specify FAMILY involvement Ancient Arabic Order or the Nobles of the Mystic Shrine Ancient Order of Druids Ancient Order of the Foresters Blue Lodge of Freemasonry Buffaloes Lodge Daughters of the Eastern Star Eagles Lodge Eastern Star Elks Lodge The Grange International Order of DeMolay International Order of Job's Daughters International Order of Oddfellows International Order of Rainbow for Girls Knights of Columbus Knights of Malta Knights of Pythias Knights Templar Ku Klux Klan Lions Club Moose Lodge Mystic Order of the Veiled Prophets of the Enchanted Realm The Orange Order Order of Amaranth Order of the Red Cross Prince Hall Masonry Riders of the Red Robe Rotary International Scottish Rite of Freemasonry Shriners White Shrine of Jerusalem Woodmen of the World York Rite of Freemasonry Other... Other Lodge/Society Involvement for FAMILY?Recent Death / Other LossHave YOU experienced a Recent Death or Other Loss? Yes Date(s) of occurrencePlease describeHas anyone in your FAMILY experienced a Recent Death or Other Loss? Yes Relationship to you (mother/father, grandparent etc.)TraumaHave you experienced a traumatic event? Yes Describe the eventDo YOU experience continued symptoms from exposure to Trauma? Yes Please describeDoes a FAMILY MEMBER experience continued symptoms from exposure to Trauma? Yes Relationship to you (mother/father, grandparent etc.) Verbal AbuseHave YOU ever experienced prolonged periods of Verbal Abuse? Yes When?(Please let us know if this is Past, Present, or Past and Present)Describe frequencyDescribe intensityHas anyone in your FAMILY ever experienced prolonged periods of Verbal Abuse? Yes Relationship to you (mother/father, grandparent etc.)Physical AbuseHave YOU ever experienced Physical Abuse? Yes When?(Please let us know if this is Past, Present, or Past and Present)Describe frequencyDescribe intensityAre you currently afraid for your safety? Yes No Please describe and provide a timeline of occurrence(s).Has anyone in your FAMILY ever experienced Physical Abuse? Yes Relationship to you (mother/father, grandparent etc.)Sexual ProblemsHave YOU ever experienced Sexual Problems? Yes What type? Infidelity Low Libido Porn Other health complications present Other:Treatment receivedHas anyone in your FAMILY ever experienced Sexual Problems? Yes Relationship to you (mother/father, grandparent etc.) 12 - Medical InformationMedications* I have current or recent medications prescribed for emotional or mental stability. I do not have any medications prescribed for emotional or mental stability. Current or recent medications prescribed for emotional or mental stability.* 13 - Religious informationBriefly describe your religious history, including but not limited to, denominational affiliations over your lifetime:*I have personal experience or my family is still connected to:Check any that apply. Catholicism Jehovah's Witness Mormonism, Church of Jesus Christ of Latter Day Saints Primative Baptist Witches Coven Other Non-Evangelical or Protestant Religion Present relationship to (or perspective of) God:*This is a great place for a short summary of your testimony. Just about done!What else would you like us to know that was not previously stated on this intake form?Type Name First and LastElectronic Signature*Your electronic signature notes that the information provided is correct to your knowledge. You consent to providing this information to Blue Fire Legacy to only be used for its intended purposes. By checking this box, I acknowledge my electronic signature.
