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Cart
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Home
About Dr. Nioka
Meet Dr. Nioka
Book Dr. Nioka for Speaking
Meet the Staff
Video Blogs by Dr. Nioka
Submit a Testimony
Upcoming Events
Presentations & Awards (ODK)
Shop
Book Counseling Session
Consultation
Resources for Abuse Victims & Other
Blog
Events
J. Kenkade Publishing
Christian Counseling Enrollment Form
Name
*
First Name
Last Name
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Country
(###)
###
####
Age
*
Religion
*
Place of Employment
*
Sex
*
Male
Female
How many children do you have?
*
Names of Children?
*
How many children at home are from a previous marriage?
*
Is your Father alive?
*
Yes
No
Unknown
Is your Mother alive?
*
Yes
No
Unknown
How many children are from a previous marriage?
Was your PARENTAL HOME EVER BROKEN BY:
*
Death
Divorce
Separation
Desertion
If any of the above applies to you, at what age did this occur? How did you feel?
Which parent in the above was lost from the home?
Father
Mother
Did your mother or father remarry?
If so, which parent and at what age?
How did you feel about your stepparent?
Do you have a good or bad relationship with your father?
Answer and explain:
Do you have a good or bad relationship with your mother?
Answer and explain:
Do you have a good or bad relationship with your siblings?
Answer and explain:
Was PARENTAL FAMILY a closely-knit family?
*
Yes
No
Is it close now?
Yes
No
Did your family change residences (move) often?
*
Yes
No
If the answer to the above is yes, why?
How many schools did you attend prior to college?
Marital Staus:
*
(Please check)
Single
Married
Separated
Annulled
Divorced
Widow(er)
Cohabitating
To the above, how long?
Spouse's Name?
If previously married, please give dates and how dissolved.
Describe your relationship with your spouse.
*
(If not married, your parents, etc.)
What is your placement in your family?
*
(Please select one)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Brothers' ages
(place a comma between ages)
Sisters' ages
(place a comma between ages)
Are you adopted?
*
Yes
No
Are any siblings adopted?
Yes
No
If yes, what are their ages and how many are there?
If you are a twin, are you identical?
*
Yes
No
Have you ever been in the military?
*
Yes
No
If yes, what branch?
Were you in combat?
Yes
No
In Vietnam?
Yes
No
Any military honors medals?
Yes
No
Type of discharge?
What is the highest grade you completed in school and in what year?
What is the highest degree you have received?
(Circle One)
AA
BA/BS
MA/MS
MSW
MTh
MDiv
MBA
RN
LPN
MD
DD
ThD
PhD
Other
What was your major? Minor?
Your occupation?
(Where you work)
Name of your employer?
How long employed here?
If you could be anything or ayone you wanted, who or what would you be?
*
(Be specific)
Spouse's Employer and Occupation?
Check the item that best describe or relate to the reason you need to receive counseling
*
Choose all that apply:
Sexual abuse
Depression
Anger
Anxiety
Nervousness
Fear
Self-doubt
Guilt
Suicidal
Loneliness
Religious doubts
Marriage problems
Bitterness
Sexual concerns
Adultery
Stress
Lack of Purpose
Addictions
Anger with God
Loss of Love
Relationship with Parents
Relationship with children
Relationship with others
Loss of faith in God
Loss of faith in self
Loss of faith in others
Loss of hope
Loss of meaning
Loss of feelings or thoughts
Loss of self-respect
If you are female, have you had any discontintued pregnancies?
Yes
No
Have you ever been arrested for anything other than a traffic violation?
*
Yes
No
How old were you when you left your parental home?
Have you ever been institutionalized for any problem(s)?
*
If so, please explain.
Have you sought help previously?
*
(If so, from whom? When? Outcome?)
Are you a Christian?
*
Yes
No
Do you believe in God?
*
Yes
No
Thank you!
