Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

If Married, on What Date?

MM

DD

YYYY

Please check all the following that apply to you at this time:

I feel depressed

I feel hopeless

I feel angry

I feel anxious

I feel fearful

I struggle with anger

I feel sad

I struggle with bitterness

I am having marital problems

I have children

I abuse alcohol

I use prescription drugs

I view pornogrpahy

I have committed adultery

My spouse is a poor communicator

I do not attend church regularly

Jesus is important in my life

I strongly fear rejection

I think of suicide

I feel worthless

I struggle with my in-laws

I struggle as a parent

I use illegal drugs

I abuse prescription drugs

I struggle sexually

My spouse has committed adultery

I am a poor communicator

I do not read my Bible often

I don't think about Jesus much

I have been sexually abused

I have been verbally abused

I have been physically abusive

I have been physically abused

I have been sexually abusive