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Care Intake Form

(Please Note: All Information is Confidential)

Your name *

Last name

Email address *

Personal Information

Phone number *

Phone type

Gender *

Marital status

Birthdate

Religious Background

Do you regularly attend church? *

Yes

Where do you see yourself spiritually in this season of your life?

Are you currently experiencing any of the following? *

Check all that apply

Anger/Frustration

Fearfulness

Prolonged Sadness

Confusion

Loneliness

Hopelessness

Guilt over the past

Difficulty making a decision

Intrusive thoughts

Unsure of salvation

Spiritual concerns/confusion

Distance from God

Withdrawing from others

Financial problems

Employment problems

Conflicts with co-workers

Social/relational stress

Parenting struggles

Family tension

Marital difficulties

Family/marital violence

Past abuse: physical/sexual

Past abuse: emotional/neglect

Physical problems

Alcohol use/abuse

Substance use/abuse

Gambling problem

Pornography use

Sexual concerns

Other

Present Situation

Is there anything else important for the placement coordinator or your caregiver to know about, and that you have not written about in this form?

If so, please explain here.

Please state your goal(s) for seeking care.

How do you hope to benefit from this?

Please describe what you have done so far to solve the problems you mentioned above.

The more information you can give us, the better we can help you.

Please describe the most important thing you are seeking help for. *

How long has this present situation lasted?

Please estimate the severity of your problem(s).

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Grace Community Church
office@gracechico.org
530-343-5528

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