Consultation Form

Client's Name

First Name

Last Name

Client's Email

Phone

If client is a minor, provide parent's number

(###)

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Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How many people are seeking counseling?

What is your age?

Spouse's Name

For Marriage Counseling & Pre-Marital Counseling Only

Spouse's Age

For Marriage Counseling & Pre-Marital Counseling Only

Spouse's Email Address (if spouse will be attending)

For Marriage Counseling & Pre-Marital Counseling Only

Names AND ages of other clients who will be attending

Parent/Guardian's Name

Only if client is a minor

First Name

Last Name

How did you hear about Dr. Nioka Smith Counseling?

If a client of Dr. Nioka's referred you, what is their name?

Tell me a little about what's going on? What areas of your life would you like to work on?

PLEASE BE DETAILED. Anything you share is 100% Confidential.

What is your Marital Status?

What methods have you previously tried?

What are you looking for in a Christian Counselor?

What questions do you have about Christian Counseling?

Is there anything else you would like the counselor to know prior to your session?

Please choose a category.

Individual (1 person)

Couple's (2 People. Ex: Husband/Wife; Boyfriend/Girlfriend; Mother/Daughter; 2 Cousins, etc.)

Family (3-5 People, Nuclear family-a family and their "dependent" children)

Group Counseling (3-20+, non-family, members of an organization or church, extended family, parents and their "independent" children, etc.)

Name of person filling out this form

Date