Counseling Application for Minors

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WE WANT TO GET TO KNOW YOU A LITTLE BIT... Please fill out this form as best you can. Be honest and specific. It should take you no more than 30 minutes. We look forward to meeting you!

Basic Information

MM slash DD slash YYYY

Tell u about your school.*

Reasons for Counseling

Why are you filling out this form?*
Do you have any health problems that would make it difficult for you to sit in counseling?*
Have you ever been to counseling before?*

Tell Us About Your Family

Are you growing up in a "typical family" with mom and dad?*
Dad's Name
Mom's Name

What has it been like to grow up in your family?

Healthy rules - We have rules but I can give input and I don't feel burdened by them.*
Affectionate - My parents often tell my they love me and show me affection.*
Religious - Church and faith are important in my family.*
Only rules - We have a lot of rules. I feel like I'm not heard or understood.*
Perfection - I feel a lot of pressure and often don't feel like I'm good enough.*
Substance Abuse - Someone in our home has struggled with alcohol and/or drugs.*
Critical - Little or no encouragement; I'm often told that I mess things up.*

Details About Your Life

For example: - Dad: Teaches me a lot of things - Mom: Unconditional love -Coach: Believes in me

Personality Information

Which 3 words would you use to describe yourself?*
What other words describe you well?*
For Example: "I have never been good enough." "I am not smart." "Nobody loves me."

Additional Information

Are you taking any prescription medications?*
Have you ever used drugs for non-medical purposes?*
Have you ever been arrested?*
Do you have problems sleeping?*
Do you have problems eating (too much or too little)?*

Advocate Information

All the people who come to us need to bring a friend with them. This is someone who knows you pretty well and who you trust. They should be Christ-followers and should have time to invest in you. YOUR PARENTS MAY HAVE TO HELP YOU CHOOSE SOMEONE. If you and your parents cannot name an advocate right now, please use one of your parents for now.
Advocate's Name*

Type Your Name to Sign!

Once you click "SUBMIT" you will have completed the application. We will work with your parents to get all other details for counseling arranged. Thank you for taking the time to help us learn more about you!

Your Twelve Stones Team

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