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Hope for All
Page 1 of 3
Name
Street Address
Address (cont)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
Email
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
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31
Year
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
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1945
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1947
1948
1949
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1951
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1955
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1958
1959
1960
1961
1962
1963
1964
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1966
1967
1968
1969
1970
1971
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1974
1975
1976
1977
1978
1979
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1981
1982
1983
1984
1985
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1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Sex
male
female
Occupation
Name
Date of Birth
Sex
male
female
Spouse's Occupation
Please enter your Spouse's Information:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
If you are interested in coming to the Ranch of Hope counseling program, please fill out and submit the following form.
Page 2 of 3
Additional Information:
Number of Children
Select Number
0
1
2
3
4
5
6
7
8
9
10
11
12
13
If you have children, please list each one's name, age, and sex:
Are you a practicing Christian?
Yes
No
What church do you attend?
How often do you attend church and church activities?
Select
Occasionally
1-3 times per week
4-6 times per week
7 or more
How often do you read your bible?
Select
Occasionally
1-3 times per week
4-6 times per week
every day
How would you describe your prayer life?
Select
I almost never pray
I pray when things are bad
I pray occasionally
I pray frequently
I pray every day
How many hours of sleep do you get per night?
Select
less than 5
5 to 6
7 to 8
more than 8
Do you have trouble sleeping?
Yes
No
Do you typically have nightmares?
Yes
No
Do you suffer from fatigue that affects your
daily activities or work?
Yes
No
Do you have any medical or physical problems
that affect you emotionally?
Yes
No
Are you sexually active?
Yes
No
Do you enjoy sex?
Yes
No
Page 3 of 3
Please review the list of symptoms/concerns below, and select all that apply to you:
Spiritual Concerns
Depression
Anxiety
Self-Destructive Behaviors
Recent Suicidal Thoughts
Anger/Aggression/Violent Behaviors
Relationship Problems
Marital Concerns
Chemical/Substance Abuse
Other Addictions
Body Image/Eating Disorders
Financial Concerns
Grief/Loss
Traumatic Experience(s)
Abortion
Fear
Feelings of Guilt
Physical Abuse
Verbal/Emotional Abuse
Sexual Abuse
Sexuality/Sexual Issues
Other: (specify below)
Elaboration on symptoms:
To what extent do these concerns affect your daily life?
Briefly describe your primary reasons for seeking counseling?
Is there any other information that you would like to share with me?
How did you hear about Ranch of Hope?
Select
Friend
Church
Website
Other
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