Forms – The Owen Center

Counseling Agreement

Before you enter your information, please take a moment to view the counseling agreement. To read over the agreement CLICK HERE. By selecting "Yes" in the following question, you acknowledge that you have read over and agree with the Counseling Agreement. If you have any questions about this, please call our office or email us at office@theowencenter.com.

Have you read and agree to the Counseling Agreement?*

Yes
No

By selecting "Yes" you acknowledge the following:*

- You understand the counseling agreement. - Your counselor is obligated by state law to report any incidents of suspected or obvious child abuse or neglect. - Your counselor may ask your permission for another counselor/perspective counselor to sit in a session. - Your counselor might be required to divulge information to appropriate civil authorities if there is an indication that you or someone else might otherwise be harmed or be at risk of abuse or neglect.

Yes
No

Personal Information

Name*

First Last

Date

Birthdate

Gender

Address (street, city, zip)

Email*

Phone #*

Marital Status:

Were you referred to us by someone? If so, who?

Religious Affiliation and Current Church:

Emergency Contact and Phone #:

In a few sentences, please let us know why you are seeking counseling.

How do you expect counseling to help your present situation or condition?

With whom are you living? How long have you been there?

Do you have someone you can talk to about personal issues in your life? (If yes, who?)

Where do you fall in the birth order of your family?

"___ of ___ children"

How would you describe your childhood? Also list the members of your family of origin and how you get along with each.

What would you change about your family if you were given the opportunity to do so?

How do you feel about being here?

It's fine with me, I need to be here
I do not want to be here
I don't care either way

Check any emotions that you experience most often

Place of employment (if applicable)

Are you currently in school? If yes, where and what year are you?

Have you ever been in counseling or therapy before? If yes, what was the outcome of that experience?

When was your last medical check up?

Are you currently on any medication(s)? If yes, please list the name of medication and prescribing physician.

Do you have any history of substance abuse or addiction? If yes, please describe briefly.

Please check any that apply to you:

Marriage and Family History (If Applicable)

Name of Spouse (If applicable):

Describe your marriage

When were you married? Name and age of spouse?

Have you been married before? If yes, how did that end?

To what degree do you share similar values in regard to gender roles?

To what degree do the two of you share values in regard to religion?

To what degree do you share similar values in regard to finances?

To what degree do you share similar values in regard to divorce?

What is your current level of marital stress?

To what degree do you have family and friends supporting your marriage?

If you have children, list their names and ages. How do you get along with each one? Any issues?

Is there anything else that may be helpful for us to know before the first appointment?

Emergency contact: Name, number and relationship*

Counseling Investment you are willing to pay:*

We ask that those we counsel invest in their own counseling by donating to the Center according to ability. The scale below suggests the appropriate investment according to your Family Annual Income and the expected Investment per hour: $0-$12k/$25 per hour; $13k-$24k/$40 per hour; $25k-$40k/$50 per hour; $41k-$55k/$60 per hour; $56k-70k/$80 per hour; $71k-$85k/$90 per hour; $86k and up/$100 per hour.

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Name

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The Owen Center Personal Profile Form

Counseling Agreement

Personal Information

Marriage and Family History (If Applicable)