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We Are Coming

New Client Questionnaire

Please complete the below questionnaire prior to your session.
If you experience overwhelming emotions, please stop and contact us via phone or text at 919-945-6778 or dial the national crisis hotline at 988.

Gender at Birth
May we leave messages here?
Are thy willing to participate in counseling?
Was your father present in your life growing up?
Was your mother present in your life growing up?
Was someone else involved in raising you?
Do you have any children?
Have you been baptized?
Is Jesus Christ your Lord and Saviour?
Have you had counseling before?
Have you seen a psychiatrist before?
Have you participated in any of these therapies?
Have you used drugs for anything other than medicinal purposes?
Do you drink alcohol more than once a week?
Which of the following words best describe your home of origin (check all that apply):

Thanks for submitting!

I will review your answers and schedule a time to discuss them in session. If this form caused any feelings to emerge that were unexpected or you need to talk about before the first session, please reach out or check out our resource page for emotional relaxation exercises.- Susanne

General Information

Emergency Contact

Mariage & Family Info

Work & Education

Church Background

Health and Background

Getting to know you...

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