Application for CHILDREN Pastoral Counselling

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To be completed by parent or guardian requesting services for a minor child. This information will help your counselor understand your child. It, as
All communications with your therapist, will be kept confidential to the full extent of Georgia Law.

BACKGROUND INFORMATION DATE

Child's Name

Date of Birth

Age

Child’s Address

Number Street County

Home Phone:

City State Zip Code

Child lives with: Child lives with: Both biological parents Mother Father Mother & Stepfather Father & Stepmother Others

If parents are divorced, describe custody arrangements:

INFORMATION ABOUT CHILD’S MOTHER:

Mother’s Name

Race

Age

Employer

Occupation

Hrs/wk

Employer’s Address

Can you be contacted at work by phone? Can you be contacted at work by phone? Yes No

Phone

Ext

Religious Denomination

Church

Member Member Yes No Active

Describe any physical problems you have that require medication or physical care

Are you currently receiving medical treatment? Are you currently receiving medical treatment? Yes No

Physician:

Medication(s) currently using: Medication(s) currently using: Yes No

If yes, when? With whom and for how long?

INFORMATION ABOUT CHILD’S FATHER:

Father’s Name

Age