Client Background Information

Please fill out the form below, read and check the red-highlighted "Policies and Procedures of CCA" link at the bottom of the form, and click "Submit Information." All fields are required, so please fill them out to the best of your ability. Estimate where necessary.

Please note that the contents of this form are transferred over a secure connection and are encrypted before they are sent to us. Your personal information will be kept confidential.

Personal Information
Phone
Use between 9am and 3pm?
For confidential messages?
Home Phone:
Work Phone:
Mobile Phone:
Insurance Information
Counseling and Medical Information
Referral and Other Contact Information
Faith Information

Faith Practice Survey *derived from the Duke Religion Index

Please answer these 2 statements looking back at the past twelve months.

The following section contains 3 statements about religious belief or experience. Please mark the extent to which each statement is true or not true for you.

Family Information

Please provide the following information concerning your family. (To provide information about each family member, please click the appropriate tab.)

Father's Personal Information

Mother's Personal Information

Brother (1)'s Personal Information

Brother (2)'s Personal Information

Brother (3)'s Personal Information

Brother (4)'s Personal Information

Sister (1)'s Personal Information

Sister (2)'s Personal Information

Sister (3)'s Personal Information

Sister (4)'s Personal Information

List all your children from your present, or any previous marriages, giving the following information on each child. (Please list any deceased children and indicate age at death.):

Child (1)'s Personal Information

Child (2)'s Personal Information

Child (3)'s Personal Information

Child (4)'s Personal Information

Child (5)'s Personal Information

Child (6)'s Personal Information


It is important to the success of your counseling that you understand, consent to and cooperate with these professional guidelines. After you read it, we suggest you print this document to keep for future reference.

I have read and agree to the Policies and Procedures of CCA.

Three things will last forever - faith, hope, and love.