Counseling Survey Form
This survey form is not for the purpose of eliminating applicants,
but to provide basic confidential  information to WPC that I may provide you with more effecient and better counseling.
Please print, complete, and mail along with a $50.00 donation to:
Whole Person Counseling, 342 S. Chadbourne, San Angelo, Texas 76903.
You may also use Pay Pal to make a donation.

This form is not meant to be used for online counseling.
Date ___/___/___  Your full name  _____________________________________ Sex:   M  F
Date of Birth ___/___/___  Race _____________ Nationality ___________________________
Marital Status: Married ___, Single ___, Divorced ___, Separated ___, Widowed ___,
Name of Spouse ___________________________ Previous Spouse __________________
Your Address __________________________________ Zip _______ Ph ___________________
Employment ____________________________  Years/ Months ______ Ph. _____________
Children's Names & Ages ________________-____, __________________-____, ________________-____,   _________________-____,   _________________-____PARENT or GUARDIAN if you are a minor _____________________________________ Note: minors must have a concent form from a parent or guardian to receive counseling.PHYSICAL: (Please complete by checking or filling in the blanks) Do you have any physical difficulties? Yes ___ No ___.  Please list any difficulties ___________________________________________________________________________ ______________________________________________.   Have you had any recent changes: in weight ____ sleep ____ diet _______________ rest _______________.   Are you currently taking any medications? Yes ___ No ___.     Please list __________________________________________________________ ___________________________.  Have you ever used drugs, tobacco, or alcohol?  Yes ___ No ___.    Any current use? _______  If yes, what? _____________________________________.

MENTAL/EMOTIONAL:  (Please complete by circling, checking,or filling in blanks)
I am often or often feel . . .  Absent minded, Forgetful, Confused, Frustrated, Fearful, Lonely, Depressed, Angry, Bitter, Jealous, Ashamed, Guilty, Worthless, Suicidal, Anxious, Worried, Tired, Sad, Hopeless, Hurt, Rejected, other feelings ______________________.     Do you have nightmares? Yes ___, No ___.  Do you have uncontrolled thoughts?  Yes ___  No ___.  If so, please explain ____________________________________________.  Is there anyone that is holding a grudge against you? _____.  If so, have you asked their forgiveness? _____.  Is there anyone who has hurt you that you have not forgiven? ______.  Is there something important that you would like to change about yourself? _____  What?_______________________________ ________________.  My greatest hurt or disappointment has been _______________________ _______________________________________________.   The thing that makes me the most angry is ________________________________________________.  I become very depressed when _______________________________________________________. I feel guilty about ____________________ _______________________________________________________________________.

SPIRITUAL:  Are you a member of a local church? ______  Church name _______________________________________ ____________________________.  How often do you attend? _____________________.     What is the name of your minister? ________________________.   Do you consider yourself a Christian?  Yes ___, No ___.  Is your spouse a Christian?  Yes ___ No ___.  How often do you read the Bible?  Daily ____ Weekly ____ Seldom _____.  How do you expect to get to Heaven when you die? __________________ ________________________________.   Have you been baptized in water as a demonstration of your faith?  Yes ___, No ___.   Have you been baptized in the Holy Spirit since you became a Believer? ______.  Have you prayed about your situation?  Yes ___, No ___.  Have you received counsel from anyone that is in authority over you?  Parent ___, Pastor ___, Employer ___, or other ________.  What? _______________________________ ________________________________.  Have you made a commitment to God that you have not kept? _____.  Has God told you to do something that you have not done? _____.    Do you have any known sins that you have not confessed to God? _____.  Do you feel that God has forgiven you? _____.

SOCIAL: (Please underline appropriate answers)
1. I believe most people . . .    a. Like me.   b. Dislike me.  c. Reject me.  d. Are indifferent to me.
2. My relationship with my father was/is . . .   a. Good.  b. Fair.  c. Abusive.  d. None.
3. My relationship with my mother was/is . . .  a. Good.  b. Fair.  c. Abusive.  d. None.
4. For me . . .    a. It is difficult to make friends.  b. It is easy to make friends.
5. I find myself being . . .  a. Passive   b. Aggressive   c. Assertive    . . . toward others.
6. I believe that most people . . .  a. Understand me.  b. Don't understand me.
7. I find myself  . . .  a. Accepting most people.  b. Being critical of most people.
8. Others would describe me as ______________________________________________________.
9. I would describe myself as ________________________________________________________.

HISTORY:  Has your parents had any physical, mental or emotional, or spiritual difficulties? _____  If so, please explain ___________________________________________________________ _______________________. Have your parents ever been involved in any of the following:  (please underline)  1. Fortune telling (palm reading, tarot cards, tea leaves, crystal ball, Ouija board, astrology, or other). 2. Studied or been a member of an Eastern religion (other than Christianity).  If so, what _________________   3. Studied or been a member of a Christian Cult (Mormon, Jehovah Witnesses, Worldwide Church of God).   4. Have your parents studied or been (in any way) involved in witchcraft (white or black magic) or Satanism? _____  If so, what ____________ ______________________________.   What was/is the spiritual beliefs of your parents _______ ___________________________________________________________________________

PERSONAL CONTACT: Do your have any books, music or artifacts associated with the worship of false religions? _____.  Have you been a part of or done any extensive studies of false religions? _______  If so, what? ________________ __________________________ Have you been in any way involved in the occult? _____   If so, what? ______________________________ Do you have or have you listened to Rock music (Christian or otherwise)?  _____  Have you allowed yourself to be hypnotized or put in a trance or used channeling?  If so, what _________________ _______________________.

PREVIOUS COUNSELING:  Have you had previous psychological or psychiatric care? ______   When? ______________  With whom? __________________________________  List any diagnoses given  _______________________________
__________________ You were referred to W.P.C.  by _________________________________________.

Thanks,
Basil Frasure, Ph.D.

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