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Mourning Dove Counseling

4080 McGinnis Ferry Road

Building 1200, Suite 1202

Alpharetta, GA 30005

678-596-9594

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New Client Questionnaire

Please complete the following form prior to your first session.

First name*

Last name*

Phone*

Email*

Address

Spouse's First Name

Spouse's Last Name

Date of Birth*

Spouse's Date of Birth

Emergency Contact Full Name

Emergency Contact Phone

Marital Status

Wedding Date (if married)

Date Separated, Divorced, Widowed (if applicable)

Previous Marriages

Children

Child 1 Name

Child 1 Age

Child 2 Name

Child 2 Age

Child 3 Name

Child 3 Age

Child 4 Name

Child 4 Age

Child 5 Name

Child 5 Age

Education and Work

Occupation (where do you work and what is the nature of the work)

Do you find this work satisfying?

Last Year of Education Completed

Additional Educational or Professional Training

Family of Origin

Father's Name

Father's Age

Mother's Name

Mother's Age

Brother 1 Name

Brother 1 Age

Brother 2 Name

Brother 2 Age

Brother 3 Name

Brother 3 Age

Sister 1 Name

Sister 1 Age

Sister 2 Name

Sister 2 Age

Sister 3 Name

Sister 3 Age

Significant Childhood Events (divorce, deaths, sickness, traumas, etc.)

Spiritual Background

Do you attend church regularly?

If attending, please provide the name of the church?

How would you characterize your relationship with God?

Reasons for Seeking Counseling

Please briefly describe the reason you are seeking counseling.

Please briefly describe any physical problems requiring medication or therapy.

Are you currently receiving medical treatment?

When did you last consult with a primary care physician?

Please list the names and dosage levels of any prescription medications you are taking.

Please list the therapist names and addresses along with the relevant dates of any previous counseling sessions.

Please select any of the following issues that concern you.

Child Abuse

Anger

Bitterness

Resentment

Difficulty Communicating

Eating Difficulty

Education

Family Problems

Fearfulness

Financial Problems

Grief / Loss

Marital Problems

Personality Conflicts

Physical Problems

Relationship Problems

Problems with Children

Problems with Parents

Spiritual Concerns

Sexual Concerns

Stress / Anxiety

Suicidal Thoughts

Trouble Making Decisions

Unhappiness

Use of Alcohol

Use of Alcohol by Family Member

Other Addiction

Work

Other

What goals do you hope to achieve through counseling?

Contact Us

Tell us how we can help, and we’ll be in touch. We typically respond within one business day.