Adult Intake Form

Thank you for taking the time to complete this information. It will be used to help navigate the time that we have working together. If both you and your spouse are participating in the sessions, two separate forms need to be completed apart from the other spouse.

Please dedicate 30-60 minutes of uninterrupted time to thoughtfully answer each question. If you need to step away while in the middle of filling out the form, you can "Save and continue later" with the personal link that will be emailed to you.

"*" indicates required fields

Step 1 of 14

1 - Client Information

Legal Name*

Prefix First Last

Name you prefer (nickname)

Sex*

Male

Female

Age*

Please enter a number from 1 to 999.

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 Information

Address*

Street Address Suite/Apt # City State / Province / Region ZIP / Postal Code Country

May we send mail here?*

Yes

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

Mobile Phone*

Home Phone

Work Phone

WhatsApp Number

Select any phone lines that we may leave voice messages on.*

Mobile Phone

Home Phone

Work Phone

Email*

Enter Email Confirm Email

3 - Emergency Contact

In 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 - Employment

Are 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.

5 - Education

Are 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 Goals

Why 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 = Way to Extreme Distress)

7 - Relationships

Children

Do you have any Children?

Yes

Child(ren) First name(s) and Birthdate(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)

Engaged

Are 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)

Marriage

Are you currently Married?

Yes

When did you get Married?

Any prior marriages?

Yes

Are you experiencing distress or difficulty within your marriage?

(ie: the context of this relationship or any undesired status changes)

Widow or Widower

Are 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)

8 - Previous or Current Counseling

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.

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.

Therapist 1

Location

Dates

Reason

Outcome

Therapist 2

Location

Dates

Reason

Outcome

Additional Notes

We 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 Health

Please select any of the following problems that pertain to you and/or your family. If the issue is not relevant, select 'No'.

ADHD

Have YOU been diagnosed with ADHD?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

If not diagnosed, do you have suspicions that you struggle with ADHD?

Yes

Has a FAMILY MEMBER been diagnosed with ADHD?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Ambition (In Excess or Lack Of)

Do YOU feel you have an excess of ambition or have little to no ambition at all?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

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.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Anger / Temper (In Excess / Lack Of)

Do YOU feel you are quickly angered or have no temper at all?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER GET quickly angered or have no temper at all?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Anxiety

Have YOU been diagnosed with or experience Anxiety which impairs your quality of life?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER been diagnosed with or experience Anxiety which impairs their quality of life?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Communication

Do YOU feel YOU struggle with Communication or communicating YOUR Feelings??

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER struggle to communicate ideas or emotions?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Compulsivity / Impulsive Behavior

Have YOU ever exhibited signs of Compulsive or Impulsive behavior?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER have compulsive or impulsive behaviors?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Depression

Have YOU ever been diagnosed with depression or experience depression to the extent that it negatively impacts your quality of life?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present.)

Has a FAMILY MEMBER ever been diagnosed with depression or experience depression to the extent that it negatively impacts their quality of life?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Emotional Awareness

Do YOU feel that you lack emotional awareness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Do you feel a FAMILY MEMBER lacks emotional awareness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Emotional Volatility

Do 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

When?

(Please let us know if this is Past, Present, or Past and Present)

Do you have a FAMILY MEMBER that experiences Emotional Volatility?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Fears

Do YOU feel that you experience overwhelming or pervasive Fear?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Do you have a FAMILY MEMBER that experiences overwhelming or pervasive fear?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Grief

Do YOU feel that you experience intense or overwhelming grief?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience intense or overwhelming grief?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Guilt

Do YOU feel that you experience intense or overwhelming guilt?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience intense or overwhelming guilt?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Hopelessness

Do YOU experience prolonged feelings of Hopelessness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER experienced prolonged feelings of Hopelessness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Inferiority Feelings

Do YOU frequently experience feelings of Inferiority?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER experienced frequent feelings of Inferiority?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Loneliness

Have YOU experienced prolonged feelings of Loneliness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER experienced prolonged feelings of Loneliness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Loss of Control

Do YOU frequently experience feelings of Losing Control?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER experienced frequent feelings of Losing Control?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Making Decisions/Decision Paralysis

Do YOU frequently experience difficulty making decisions?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER frequently experience difficulty making decisions?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Memory

Have YOU ever experienced memory issues?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience memory issues?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Nervousness

Do YOU ever experience frequent or persistent Nervousness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience frequent or persistent Nervousness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Panic

Do YOU experienced intense or overwhelming Panic?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experienced intense or overwhelming Panic?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Racing Thoughts

Do YOU experience Racing Thoughts frequently or regularly?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience Racing Thoughts frequently or regularly?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Self-Control

Do YOU experience a Loss of Self Control on a regular basis?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience a Loss of Self Control on a regular basis?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Shyness

Do YOU frequently experience the feeling of Shyness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER frequently experience Shyness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Stress

Do YOU constantly experience the feeling of being stressed out?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER have a pattern of feeling stressed out?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Suicidal Thoughts

Do YOU experience Suicidal Thoughts?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER experienced Suicidal Thoughts?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Unhappiness

Do YOU experience Unhappiness frequently?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience Unhappiness frequelntly?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Unwanted Thoughts

Do YOU experience Unwanted Thoughts frequently?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience Unwanted Thoughts frequently?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

10 - Physical Health

Please select any of the following problems that pertain to you and/or your family. If the issue is not relevant, select 'No'.

Abortion

Have YOU ever had an Abortion?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER ever had an Abortion?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Addiction (Alcohol / Substance Abuse / Gambling / Sexual)

Have YOU ever experienced an addiction?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

If Yes, then please list the addiction you struggle(d) with and indicate whether or not you have adequately addressed this addiction.

Has a FAMILY MEMBER ever experienced an addiction?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

If Yes, then please list the addiction your family member struggles with

Bad Dreams

Do YOU experience pervasive Bad Dreams or Intense Nightmares?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experienced pervasive Bad Dreams or Intense Nightmares?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Chronic Illness

Have YOU been diagnosed with a Chronic Illness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

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 Issues

Have YOU been diagnosed with, or struggle with, Disordered Eating?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER been diagnosed with, or struggle with, Disordered Eating?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Physical Limitations

Have YOU been diagnosed with or experience long-term Physical Limitations?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER been diagnosed with or experience long-term Physical Limitations?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Pregnancy

Are 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/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Severe / Major Injury

Have YOU ever experienced a Severe/Major Injury?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Have any of your FAMILY MEMBERS ever experienced a Severe/Major Injury?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Sleeplessness / Insomnia

Do YOU experience Sleeplessness / Insomnia?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience Sleeplessness / Insomnia?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Terminal Illness

Have YOU been diagnosed with a Terminal Illness?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has a FAMILY MEMBER been diagnosed with a Terminal Illness?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

11 - Life Events

Please select any of the following problems that pertain to you and/or your family. If the issue is not relevant, select 'No'.

Difficult or Regretted Career Choices

Have YOU regretted your career choices?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Have any of your FAMILY MEMBERS regretted their career choices?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Disaster

Have YOU experienced a Disaster which currently impacts your quality of life (in any area: emotional/physical/spiritual)?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Have 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.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Job Struggles

Are YOU currently experiencing Job Struggles?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has anyone in your FAMILY experienced a pattern of Job Struggles?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Legal Matters

Are YOU involved in any Legal Matters which impact your emotional wellbeing?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Is anyone in your FAMILY involved in any Legal Matters which are impacting their emotional wellbeing?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Lodge Involvement (Eagles, Freemasons, etc.)

Have YOU ever been involved in any Lodges ( Eagles, Freemasons, etc.)

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 Involvement for YOU?

Has anyone in your FAMILY ever been involved in any Lodges ( Eagles,Freemasons, etc.)

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

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 Involvement for FAMILY?

Recent Death / Other Loss

Have YOU experienced a Recent Death or Other Loss?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has anyone in your FAMILY experienced a Recent Death or Other Loss?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Trauma

Do YOU experience continued symptoms from exposure to Trauma?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Does a FAMILY MEMBER experience continued symptoms from exposure to Trauma?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Verbal Abuse

Have YOU ever experienced prolonged periods of Verbal Abuse?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has anyone in your FAMILY ever experienced prolonged periods of Verbal Abuse?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Physical Abuse

Have YOU ever experienced Physical Abuse?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has anyone in your FAMILY ever experienced Physical Abuse?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

Sexual Problems

Have YOU ever experienced Sexual Problems?

Yes

When?

(Please let us know if this is Past, Present, or Past and Present)

Has anyone in your FAMILY ever experienced Sexual Problems?

Yes

Relationship to you (mother/father, grandparent etc.)

When?

(Please let us know if this is Past, Present, or Past and Present)

12 - Medical Information

Current or recent medications prescribed for emotional or mental stability.

13 - Religious information

Briefly 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 Last

Electronic 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 be used for only its intended purposes.

By checking this box, I acknowledge my electronic signature.

Adult Intake Form

1 - Client Information

2 - Contact Information

3 - Emergency Contact

4 - Employment

5 - Education

6 - The Nature of Your Issues and Goals

7 - Relationships

Children

Engaged

Marriage

Widow or Widower

8 - Previous or Current Counseling

9 - Mental Health

ADHD

Ambition (In Excess or Lack Of)

Anger / Temper (In Excess / Lack Of)

Anxiety

Communication

Compulsivity / Impulsive Behavior

Depression

Emotional Awareness

Emotional Volatility

Fears

Grief

Guilt

Hopelessness

Inferiority Feelings

Loneliness

Loss of Control

Making Decisions/Decision Paralysis

Memory

Nervousness

Panic

Racing Thoughts

Self-Control

Shyness

Stress

Suicidal Thoughts

Unhappiness

Unwanted Thoughts

10 - Physical Health

Abortion

Addiction (Alcohol / Substance Abuse / Gambling / Sexual)

Bad Dreams

Chronic Illness

Eating Issues

Physical Limitations

Pregnancy

Severe / Major Injury

Sleeplessness / Insomnia

Terminal Illness

11 - Life Events

Difficult or Regretted Career Choices

Disaster

Job Struggles

Legal Matters

Lodge Involvement (Eagles, Freemasons, etc.)

Recent Death / Other Loss

Trauma

Verbal Abuse

Physical Abuse

Sexual Problems

12 - Medical Information

13 - Religious information

Just about done!

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