MENTAL HEALTH INTAKE FORM Your Info Step 1Your Info Step 2Your Full Name (optional) Your Age Bracket 10- 20 years 21 - 30 years 31 - 45 years 45 yrs and AbovePrefered Name / Nickname Your Gender - Select -MaleFemaleOthersPhone no. Email Marital Status Married Unmarried OthersSpouce Name Marital status(others) With whom do you live? Employment Status Business Owner/CEO Employed Unemployed Student/NYSC RetiredTell us Your Occupation Retired Occupation Date of retirement Previous StepNext StepYour Mental Health StatusFeel free to tell us your personal statusDo you have any Disability ? Yes NoNature of disability Have you have any mental coach or material before now? Yes NoWho is your mental coach: Where is your mental coach located ? Phone Number of mental coach: Have you been taking any mental health medications lately? Yes NoTell us what Medications Do you Drink Alcohol? Not any more Yes NoFor how long now? If you quit, when did you stop? For how long did you drink alcohol? Do you smoke? I Quit Smoking Yes NoFor how long now? How how long did you smoke? If you quit, when did you stop? Do you have any addicted habits you want to share with us? Yes NoWhat is/are these habits? What are your Concern? Your preferred time of meeting with our therapist. Morning Section (between 9am - 11am) Afternoon Section (between 12pm - 2pm) Evening Section (between 3pm - 5pm)Preferred Means of Communication Phone Calls Whatsapp Calls / Chats Center Visitation Zoom Others MeansPlease tell us (other means) I consent to having The Transforming Church store my submitted information so they can respond to my inquiry.Submit Previous
