Welcome to COH AfterCare Personal Counseling!
Disclosure
COH AfterCare Ministry, LifeSpring International Ministries & Jeremy Friedman do not diagnose, cure, or prescribe medication for mental illness. Please consult with your personal physician when needed.
Please complete the following questions completely. Once you complete the form, it will automatically be returned to me. If you don't, I will need to use our session time to interview you and complete the form.
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I confirm I have read and agree to the terms above. Signature:
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What nation and state do you live in?
Example: USA, North Carolina or Canada, Alberta
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| Is English your primary language? | {"type":"radio","name":"__generic3","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"Yes\nNo"}
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Are you part of a local church body in which you attend (either in person or by livestream) at least twice a month?
| {"type":"radio","name":"__generic4","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"Yes\nNo"}
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| Your Age | {"type":"text","name":"__generic5","width":100,"value":"","size":"Normal","validation":"TN","validationMessage":"Please fill in this item.","placeholder":""}
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| Marital Status | Select oneMaleFemale{"type":"select","name":"__generic6","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select one\nMale\nFemale"}
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| Gender | {"type":"text","name":"__generic7","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
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| Your Occupation | {"type":"text","name":"__generic8","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
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| Do you have children? | {"type":"radio","name":"__generic9","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
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If yes, how many? Ages?
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What has motivated you to seek counseling at this time?
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How long have you experienced this current issue?
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Have you been in counseling before?
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How long ago was that?
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What issue(s) did you work on with the counselor?
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How are the issues you are seeking counseling for today impacting your everyday life?
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Are you currently under doctor's care for a medical diagnosis?
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If yes, please explain.
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Are you experiencing any physical symptoms that you think may be related to the challenges you are or have experienced in your life?
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If yes, please list the symptoms.
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Are you currently taking any medications for physical ailments or mental health?
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If yes, please list the medications.
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Pick four words that describe your life. Explain your choices.
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What do you expect to accomplish as a result of counseling?
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Please feel free to share any other information you think I should know about you.
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Thank you for choosing COH AfterCare Ministry for your personal counseling needs. Shalom!
