Personal Profile Individual – 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 #*

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

If you go to church, which one?

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?

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

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

When was your last medical check up?

Please check any that apply to you:

Have you been ever been married? If yes, please describe 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-$22k/$30 per hour; $23k-$44k/$50 per hour; $45k-$66k/$75 per hour; $67k-$89k/$100 per hour; $90k + /$80 per hour. If you have questions about your investment amount, please call our office 334-329-5259.

Would you like to receive our monthly newsletter?

Yes
No

Email

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The Owen Center Personal Profile Form - Individual

Counseling Agreement

Personal Information