Name *
Birth Date *
Birth Date
Address *
Phone *
Permission to call? *
Permission to text? *
Permission to leave voicemail? *
Preferred Method of Contact
Because we use a sliding scale for our counseling fees, this helps us determine what your fee will be.
Gender *
Marital Status *
Seeking counseling together? *
If yes, please have spouse complete separate info form.
If no children put N/A
Are you currently seeing a counselor, therapist, or psychiatrist for this issue or another? *
Are you currently seeing an attourney or seeking legal guidance in regards to your situation? *
Spiritual Background
Are you a member of In Focus Church? *
Are you part of a small group at In Focus Church? *
Have you made a commitment to Jesus Christ? *
Family Background
The intent of this section is not to blame, slander, nor in any way put down your family and/or ancestors. However, it is biblical that sins, curses and emotional issues can be passed down through ancestral lines. In order to better understand the issue we are addressing, we need to understand how it has affected you through your family line.
Parents marital status: *
Rate your parents' marriage: *
Current Issue
Below are lists of potential strongholds or roots that could become main issues as well as the associated symptoms or surface behaviors. Please check anything which seems to be a root or stronghold in your life or for your current issue. Please also check the "in the family" box if it runs in your family line as well.
Abandonment *
Anger *
Control *
Divorce *
Depression *
Failure *
Fear *
Illness/Infirmity *
Perfectionism *
Rebellion *
Rejection *
Religious Issues *
Sexual Sins *
Shame *
Suicide *
Trauma *
Unforgiveness *
Belief Statements
Control statements *
God statements *
Hopelessness Statements *
Identity Statements *
Physical Characteristics Statements *
Protection Statements *
Recognition Statements *
Relationship Statements *
Rejection Statements *
Unworthiness Statements *
Victimization Statements *
Schedule Availability
Check any times that you would be available for an appointment: *