Adult Intake Form Step 1 of 4 25% Adult IntakeEach adult meeting with the counselor must complete their own adult intake. Name* First Last Phone*Email* Is someone else attending counseling with you?* YES NO Who will be attending with you?*NameAgeRelationship to You Tell us about you...Date of Birth* Month Day Year Current Age*<1818-2425-3435-4445-5455-64>65Gender* Male Female Prefer Not To Share Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about MyCounselor.Online?* Google or Other Search Engine Someone I trust recommended you Facebook or Other Social Media Other Please share who referred you or how you heard about us... I am a... Pastor / Ministry Leader Foreign Missionary Foster or Adoptive Parent None Of The Above Household Income**This information helps us apply for grants to provide scholarships to those in need. <$35k $35k-$70K $71k-$150k $151k-$200k >$200k I prefer not to share. How can we help?Briefly identify what brings you into counseling.*Briefly describe the history and development of your concern from onset to the present.*What are your goals for counseling - what do you hope to accomplish?*Have you been to counseling before?* Yes No Briefly describe your previous experiences with counseling.HiddenWhat are your current stresses?HiddenPlease indicate areas of stress in your life. Marriage/Home Children/Parents Work/School Financial Spiritual Social Sexual Other HiddenPlease briefly describe the areas of stress marked above.HiddenSymptom Checklist (please check all that apply): I am dissatisfied with my life and want to change. I am dissatisfied with the current state of my family life. I am dissatisfied in my relationship with my spouse or significant other. I am dissatisfied with, confused about or have questions regarding the sexual part of my life. I am dissatisfied with my interpersonal relationships in general. I am dissatisfied with my body. In the past 3 months I have thought about how I could end my life. HiddenI have recently experienced: moodiness unusual anger or irritability anxious feelings loneliness change in sex drive change of appetite unusual fatigue difficulty sleeping nightmares resentment stomach trouble bowel disturbances racing thoughts apathy/hopelessness mental confusion or disorientation decreased energy of motivation feelings of helplessness feelings of sadness, loss, or grief inferiority feelings HiddenIn the last few months, in order to feel better about my life, I have done the following: binge eating drank alcohol used illegal drugs misused prescribed drugs ignored my normal responsibilities refused to get out of bed or do normal hygiene isolated myself from people constantly surrounded myself with people worked more than usual used pornography or erotic material acted sexually in an unusual way for me harmed myself by cutting, burning, etc. HiddenIn my lifetime I have experienced: the loss of a loved one a traumatic event sexual abuse or assault physical abuse or assault mental or verbal abuse the death of a child an abortion divorce of my parents divorce of my own the loss of someone by suicide an addictive habit living with someone who was/is addicted abandonment by important people to me exploitation by important people to me being unloved by important people to me be fired from a job something else significant to me (please describe below) HiddenPlease specify what has occurred:*HiddenCurrent Medications:MedicationDosageCondition I understand:*- I understand the payment method I provide MyCounselor.Online will be charged my membership fee every 4 weeks starting the day I begin my membership. - My membership includes 2 45-minute units of counseling every 4-week billing cycle. - If I schedule more than 2 units in a 4-week billing cycle, I will be charged an additional session fee for each unit I schedule the day of the session. - I may cancel at any time. Memberships are non-refundable. - To qualify for a Risk-Free Guarantee refund I must attend my "Right for You" first session(s). If I do not attend my scheduled session, I do not qualify for a refund. Refunds are only available following my attended session. If I do not request a risk-free guarantee refund following my first session, and complete a second session with the counselor I matched with, I am no longer eligible for a risk-free guarantee refund. - If I fail to give notice of cancellation or rescheduling requests by using the scheduling software link, calling 855-755-3797, or emailing firstname.lastname@example.org at least 24 hours before my scheduled appointment, I am responsible for the full fee of my session and I will be charged for the time I have requested to be reserved for me. I understand and agree.