New Client InformationThank you for your willingness to engage in ministry with Libby. Please answer all questions as fully and honestly as possible. Note: Fields with an * are required. Thank you. Name * First Name Last Name Email * Age * Postal Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Good Phone to leave a confidential message * (###) ### #### Responsible Party for Payment * If other than self, please provide contact information. May Libby contact this person for payment directly? * Yes No Who referred you, or how did you hear about Libby? * Emergency Contact & Phone * 1. Reason for seeking ministry at this time: * 2. Have you previously received counseling, therapy or coaching? If so, what was it like for you? * 3. Please list additional concerns or important factors in your life such as occupation, marriage, education, current living situation, romantic relationship, drugs or alcohol)? * 4. Who in your life is most supportive? (list up to 4 people and who they are to you, i.e. sibling, friend, pastor). * 5. What do you consider to be your three of your greatest strengths? * 6. Have you been hospitalized for mental health reasons? Had suicidal ideation or suicidal behavior? * 7. Are you or someone you care for in danger of being harmed? Yes No Please, explain: * 8. What do you hope is accomplished as a result of our ministry sessions? * 9. Are you currently taking any medications? Are any for psychiatric concerns? * 10. Any other things you would like Libby to know? * Thank you for signing the disclosure and submitting your information. I look forward to meeting with you! Thank you for taking the time to help me to get to know you. I look forward to meeting with you!
