Counseling Connections for Change, Inc.

A 501(c)(3), nonprofit Christian Counseling Center
We Believe Mental Health Matters!

Chief Complaint2018-10-16T16:45:00+00:00

INTAKE FORM

Counseling Connections for Change, Inc. is a 501(c)(3) nonprofit organization. Collection of demographic information is necessary to fulfill our mission as a nonprofit organization and seek outside funding support.

Counseling Connections for Change, Inc. is fully compliant with the HIPAA Standards for Privacy, Electronic Transactions and Security (including the HITECH Act and the Omnibus Rule of 2013).  Counseling Connections for Change, Inc. has implemented policies, processes, and procedures designed to ensure compliance with Federal and State information security laws, regulations, and rules, and monitors ongoing compliance efforts and maintains various reporting mechanisms that are required by law.

3 CHIEF COMPLAINT

Select the top 3 concerns for which they are seeking trouble

ADHDAddictionAdoptionAlcohol AbuseAlzheimer'sAnger ManagementAntisocial PersonalityAnxietyAsperger's SyndromeAutismBehavioral IssuesBipolar DisorderBorderline PersonalityCareer CounselingChild or AdolescentChronic IllnessChronic ImpulsivityChronic PainChronic RelapseCodependencyCoping SkillsDepressionDevelopmental DisordersDivorceDomestic AbuseDomestic ViolenceDrug AbuseDual DiagnosisEating DisordersEmotional DisturbanceFamily ConflictGamblingGriefHoardingInfertilityInfidelityIntellectual DisabilityInternet AddictionLearning DisabilitiesLife CoachingLife TransitionsMarital and PremaritalMedical DetoxMedication ManagementMen's IssuesNarcissistic PersonalityObesityObsessive-Compulsive (OCD)Oppositional DefianceParentingPeer RelationshipsPregnancy, Prenatal, PostpartumRacial IdentityRelationship IssuesSchool IssuesSelf EsteemSelf-HarmingSex TherapySexual AbuseSexual AddictionSleep or InsomniaSpiritualitySports PerformanceStressSubstance AbuseSuicidal IdeationTeen ViolenceTesting and EvaluationTransgenderTrauma and PTSDTraumatic Brain InjuryVideo Game AddictionWeight LossWomen's Issues

Marital Status (more than one answer may apply)

SingleDivorce in processUnmarried, living togetherLegally marriedSeparatedDivorced/ (number of times)WidowedAnnulmentTotal number of marriages

How satisfied are you with your current relationship status? Please put an X to indicate your level.

Extremely SatisfiedCompletely Dissatisfied

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