top of page

We Are Coming

Coastal Grasslands Scene

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

Thanks for submitting!

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

 

- Susanne Poté

General Information

Emergency Contact

Mariage & Family Info

Work & Education

Church Background

Health and Background

Getting to know you...

Subscribe for updates and inspiration.

Thanks for submitting!

© 2025 by Muck & Mire Ministries, LLC | Platform Web Design | Biblical Foundations Counseling | Nashville, Tennessee

bottom of page