Counseling Form

Counseling services are available to members and regular attenders of Winston-Salem First.

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Name *
Parent/Guardian Name
Parent/Guardian Name
If under 18 years of age.
Birth Date *
Birth Date
Please list any children and their age(s).
Address *
Home Phone *
Home Phone
Cell/Other Phone *
Cell/Other Phone
Please select the answer that best suits your situation.
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *
If you selected yes in the previous questions, who was your previous therapist/practitioner?
Are you currently taking any prescription medicine? *
If you selected "YES" in the previous question, please list them in the textbox below.
Have you ever been prescribed psychiatric medication? *
If you selected "YES" in the previous question, please provide the dates.
How would you rate your current physical health? *
How would you rate your current sleeping habits *
Please answer the question in the textbox below. You may only use numbers.
Are you currently experiencing overwhelming sadness, grief or depression? *
If you selected "YES" to the question above, approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias? *
NOTE: This only pertains to you if you selected "YES" in the previous question.
Are you currently experiencing any chronic pain?
If you selected "YES" to the question above, please describe in the textbox below.
Do you drink alcohol more than once a week? *
How often do you engage recreational drug use? *
If you selected "YES" above, how long?
Note: This only applies if you answered "YES" to the previous question.
Family Health History *
If you checked any boxes in the question above, please list out the family members that are associated with the illness. Example: Anxiety- mother.
Please describe your faith or belief in the textbox below.