CLINIC / PROGRAM LOCATION :

____ Boise, Idaho
____ Caldwell, Idaho
____ Nampa, Idaho
____ Meridian, Idaho
____ Omaha, Nebraska

NAME / ADDRESS :

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PHONE NUMBER :

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E-MAIL ADDRESS :

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AGE :

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RELATIONSHIP STATUS :

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CHILDREN :

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MEDICAL HEALTH ISSUES :

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SUBSTANCE ABUSE ISSUES :

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PREVIOUS COUNSELING EXPERIENCE :

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Please use an attached piece of paper, and respond to the questions listed below ;

* Positive Childhood Events
* Positive Achievements as an Adult / Child
* Major Professional Achievements
* Current Life Challenges
* Explain Your Most Successful Relationship
* Explain Your Most Negative Relationship
* What Lessons Did You Learn, From This Negative Relationship

Taking a serious look at your life, please rate your current life traits;

( RATE 1 FOR POOR, TO 10 FOR OUTSTANDING )