Helping people help themselves 

dedicated to strengthening the spiritual journey and restoring emotional wellness

NYCCC
Intake Form                     Date__________________

First Name_____________________ Middle Initial______
Last Name_____________________
Address_____________________ Apt# _______ City_______________

State____ Zip__________Social Security Number ______________________ 

Email _________________________________
Date of Birth _______________________ 

Home Telephone ________________________Business Telephone ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________

Cell Phone________ _____________________
Male____  Female______  Married____    Single____  Separated ____   Divorced ____
Names and ages of Children ____________________________________________________

Spouse name________________________________________________________
In what country were you born?____________________________________
Are you attending a Church ______   If so how often_______ 

Current problem:____Depression ______ Marriage ______Adolescent 

_____ Anger  ____ Sexual problem ______ Anxiety  ______  Relationship  _____ Adjustment

____ Pre marriage  _ _____ Unknown _____ Parent/Child   Other________________________________________________________________________________________________________________________________________________________________
Do you have SKYPE__________ If so, what is your Account Name________________________________
Type of Credit Card used for internet sessions    ________MasterCard    _________Visa _________PayPal
Insurance carrier ________________________________

Will you need a printed bill? _________   Policy #___________________________________
How did you hear of NYCCC?_______________________________________________________
If these sessions were successful, what would be one or more changes you might expect______________________________________________________________ _________________________

___________________                                        _________________
Client Signature                                                        Date
All information is confidential  and will only be used for session purposes. 

 Christian Counseling Center