FAMILY HISTORY ANALYSIS - LONG FORM
|
|
|
- Elwin Banks
- 7 years ago
- Views:
Transcription
1 Instructions: You are under no obligation to complete this longer version of the Family History Analysis; it is entirely optional. However, if you would like to explore more deeply the impact of family experiences on your life, including your spiritual life, the following questions can help you become aware of possible problem areas. Complex and deep emotional issues related to family of origin are not uncommon. If you become aware of such problems and you would like to work on them, we will be glad to recommend a professional counselor, who is also a spiritually mature, biblically sound believer. NOTE: If you have experienced any kind of abuse or trauma for which you have not sought counseling, exploring these questions may bring to mind painful experiences and emotions. If you find yourself becoming emotionally upset as you work through these questions, we recommend that you put this questionnaire aside and ask advice from your mentor as to whether you should speak to a professional counselor.
2 1. Please describe your father in several words or phrases: 2. What were the three main emotions your father demonstrated as you were growing up? 3. How did he show affection to you while you were growing up? Now? 4. What kind of disciplinarian was your father as you were growing up? 5. What emotions do you feel toward your father? 6. How well do you communicate with your father today? 7. In several words or phrases, please describe your father s faith as you were growing up: 8. Please use this graph to describe your closeness with your father over the time periods indicated: Level of Closeness 5 being the highest Age: Present 9. Please describe your mother in several words or phrases: 10. What were the three main emotions your mother demonstrated as you were growing up?
3 11. How did she show affection to you while you were growing up? Now? 12. What kind of disciplinarian was your mother as you were growing up? 13. What emotions do you feel toward your mother? 14. How well do you communicate with your mother today? 15. In several words or phrases, please describe your mother s faith as you were growing up: 16. Please use this graph to describe your closeness with your mother over the time periods indicated: Level of Closeness 5 being the highest Age: Present 17. How do you currently relate to your father and mother emotionally? (Put F or M next to appropriate number) Dependent Independent 18. As you look back, do you think your parents expressed their emotions in an open, direct manner? 19. Were you and your siblings able to express your emotions freely? 20. How would you describe your parents marriage while you were growing up? Happy Mostly happy Occasional problems Frequent problems Unhappy
4 21. How did they demonstrate affection toward one another? 22. What is your parents marital status? (Please circle all that apply.) Both living One deceased Both deceased Separated Divorced Remarried 23. If your parents are divorced, how old were you when the divorce occurred? 24. If your parents are divorced, what is their current marital status? 25. If your parents divorced when you were still at home, did you grow up with a step-parent? Step-brothers/sisters? 26. Please list the age and sex of all the siblings you grew up with, including yourself. 27. Please indicate the degree of closeness you enjoy with each sibling, using a scale of 1-5, with 5 being the highest. 28. Were either of your parents perfectionists or Type-A personalities? If so, which one? 29. Did either of your parents suffer from emotional problems while you were growing up? 30. Were either of your parents alcoholics or heavy drinkers? 31. Did either parent abuse prescription or non-prescription drugs? 32. Growing up, were your parents critical, judgmental, demanding, indifferent, distant, absent toward you? (Circle all that apply.) 33. Growing up, what were the main should and ought messages you received from your parents?
5 34. Were the family rules: flexible, firm or rigid? 35. How were violations of family rules handled? 36. Did you feel loved in your family? 37. Did you feel safe in your family? 38. How would you describe your parents expectations of you while you were growing up? 39. Did your parents express their expectations of you in a clear manner? 40. Did you feel your parents expectations of you were sometimes inappropriate or impossible to achieve? 41. How would you describe your parents expectations of you now? 42. Do you feel that you now have your parents approval? 43. Do you have any unresolved anger toward your parents or siblings? 44. How do you feel about the religious training you received as you were growing up? 45. What were your parents occupations? 46. Was your family financially secure as you grew up? 47. How do you currently relate to your parents financially? Dependent Independent 48. What is your best insight into how these family relationships have affected other significant relationships in your life?
WMBC Counseling Ministry Personal Data Inventory
WMBC Counseling Ministry Personal Data Inventory Please complete this inventory carefully (Question marks have been eliminated.) Personal Identification Name: Birth Date: Physical Address: Mailing Address
Discipleship Counseling
Discipleship Counseling www.gbcn.org 239.513.0044 1610 Trade Center Way Suite 3, Naples, FL 34109 info@gbcn.org Personal Identification Mr. Mrs. Miss Name Address City Zip Home Phone ( ) Other Phone (
Premarital Counseling Survey. Address: Phone: Email: Cell Phone: High school graduate? Yes No College degree? Yes No Major
Premarital Counseling Survey This survey is designed to help the counselor understand who you are, where you re at in your current relationship, and how you view love and marriage. You may find some of
Grace Biblical Counseling Ministry
Grace Biblical Counseling Ministry Personal Data Inventory Name Address Sex: Age: Date of Birth: Phone Number: Highest Education: High School GED College Graduate Post Graduate Other Education or Training
Premarital Counseling
The Rev. Dr. Alan R. Akana 1723 Teal Drive / Park City, UT 84098 / (435)658-2877 / parkcityweddings@akana.net www.akana.net/parkcityweddings Premarital Counseling The time of engagement is an important
Premarital Counseling
Premarital Counseling Congratulations on your engagement! We are excited to partner with you in preparing for your marriage. At The Austin Stone Community Church, we are committed to supporting and providing
NEUROPSYCHOLOGY QUESTIONNAIRE. (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Home address:
NEUROPSYCHOLOGY QUESTIONNAIRE (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Date of birth: Age: _ Home address: _ Home phone: Cell phone: Work phone:
Biblical Counseling General Intake Form Personal History and Problem Evaluation
Biblical Counseling General Intake Form Personal History and Problem Evaluation Identification Data Name: Phone: Date: Address: Occupation: Business Phone: Gender: Date Of Birth: Age: Education: Last Grade
Behavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
Grace Biblical Counseling 5595 Mason Road Mason, OH 45040 (513) 398-1989
Grace Biblical Counseling 5595 Mason Road Mason, OH 45040 (513) 398-1989 Welcome to Grace Biblical Counseling! We look forward to helping with your problems using the Bible. In order to be as clear as
Santa Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
Declaration of Practices and Procedures
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
41. Name and address of your physician:
Providence Biblical Counseling Ministry - Personal Data Inventory Identification Data: 1. Name: 2. Phone: 3. Date: 4. Address/City/Zip: 5. Occupation: 6. Business Phone: 7. Cell Phone: 8. Email: 9. Birth
Background Questionnaire for Diaconate Aspirants and Wives
Background Questionnaire for Diaconate Aspirants and Wives After you submit this form, click on "Home" and then my website link to return to my website to complete more forms. General Information Date
Declaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
Youth Ministry Adult Staff Application
Youth Ministry Adult Staff Application Youth Ministry Purpose Statement: Our purpose is to share the TRUTH by building RELATIONSHIPS and using our GIFTS to SERVE God. Through God s grace we will continue
Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
Declaration of Practices and Procedures
Kyndal C. Jacoby, MSW, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722 Declaration of Practices and Procedures I am
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:
Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent
SPIRITUAL GIFTS SURVEY
SPIRITUAL GIFTS SURVEY DIRECTIONS This is not a test, so there are no wrong answers. The Spiritual Gifts Survey consists of 80 statements. Some items reflect concrete actions; other items are descriptive
It s an awfully risky thing to live. Carl Rogers. her family. Daily routines that people were used to are now gone.
It s All My Fault Feelings When a Family Member Has an Accident and Loses a Limb Easy Read Volume # 18 Issue # 4 May/June 2008 Translated into plain language by Helen Osborne of Health Literacy Consulting
INTAKE FORM. General Information Name DOB Date Address: Phone: Cell Phone: Email:
INTAKE FORM General Information Name DOB Date Address: Phone: Cell Phone: Email: Marital Status (Circle One) Single Engaged Married Separated Divorced Widowed If married how long? Number of previous marriages
MASTER OF DIVINITY DEGREE ADMISSION APPLICATION
MASTER OF DIVINITY DEGREE ADMISSION APPLICATION Please Type or Print Legibly. Online Residential (Check One) Date: SSN: Desired Admission Date: Fall Spring Year: Name: Last First Middle Maiden Permanent
CHILD CUSTODY QUESTIONNAIRE CHILD CUSTODY LITIGATION CLIENT QUESTIONNAIRE
CHILD CUSTODY QUESTIONNAIRE CHILD CUSTODY LITIGATION CLIENT QUESTIONNAIRE Note: Please regard references to ex as your spouse, other parent, or caretaker. Please apply the reference to child or children
Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no
Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478
ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
Marian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.org EDWARD H. MARTIN, M.A., LPC.. MARLA S. FREEMAN, M.A.
Know the Law About Who May Pick Up a Child from Child Care
Know the Law About Who May Pick Up a Child from Child Care In California, part of a child care provider s legal responsibility for the children in her care is an obligation to let the child leave only
JENNIFER TARDELLI, MA, LPC, NCC PSYCHOTHERAPY WOMEN S ISSUES
Personal History/Life Script Questionnaire What is your main reason for coming into therapy? What is your difficulty or personal problem? Give a recent example of when and how this problem occurred and
DECLARATION OF PRACTICES AND PROCEDURES
DEE JONES ADAMS, PhD, LPC, LMFT Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, LA 70802 225-387-2287 (FAX 225-383-2722) Email: Dee@brchristiancounseling.com DECLARATION OF PRACTICES
ROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc.
ROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc. I know you have several pages of paperwork to complete, so I will only take a few moments of your time now to share some important details
A GUIDE TO WRITING YOUR LIFE STORY. Identifying information: Name and maiden name, date and place of birth:
1 A GUIDE TO WRITING YOUR LIFE STORY You are welcome to answer the following questions here or write your own essay on separate paper. If you would like to complete this on your computer ask your trainer
FAMILY QUESTIONNAIRE Please Print Clearly
FAMILY QUESTIONNAIRE Please Print Clearly The following questionnaire encompasses many aspects of your life, and the life of the alcoholic/addict. Please check and comment on the items listed below as
Building Resiliency in Kids
BRiK Building Resiliency in Kids INSTITUTE FOR HEALTH & RECOVERY Acknowledgments The original source of this curriculum was Einat Peled and Diane Davis (1995) Groupwork with Children of Battered Women:
Health Education Core ESSENTIAL QUESTIONS. It is health that is real wealth, and not pieces of gold and silver. Gandhi.
Health Education Core ESSENTIAL QUESTIONS It is health that is real wealth, and not pieces of gold and silver. Gandhi Increased Focus Classroom Real Life Connection Student Reflection Student Assessment
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet Date: Student s Name: Student s ID: Local Address: Residence Hall & Room Number or Local Street Address Personal Phone:
UWM Counseling and Consultation Services Intake Form
UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes
Date of Current Marriage/Separation: Highest Level of Education:
ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages
TRANSFORMING LIFE COUNSELING CENTER ADDICTIONS 101
TRANSFORMING LIFE COUNSELING CENTER ADDICTIONS 101 16301 Sonoma Park Drive (NW 164 th & Penn) Edmond, OK 73013 Kyle McGraw Licensed Alcohol and Drug Counselor Licensed Professional Counselor (405) 246-LIFE
River Canyon School RIVER CANYON SCHOOL APPLICATION FOR ENROLLMENT. To be completed by parent or guardian.
River Canyon School Early Childhood Programs inspired by Waldorf Education River Canyon School 730 25 Rd Grand Junction, CO 81505 Contact us at 970-639-0514 or e-mail info@rivercanyonschool.com RIVER CANYON
Birth Parents Application of Services
If yes, who? self parent grandparent If yes, who? self parent grandparent With what tribe? With what tribe? Single Single Married Marriage Date(s) & Place: Married Marriage Date(s) & Place: Spouse Name:
What To Expect From Counseling
Marriage Parenting Spiritual Growth Sexuality Relationships Mental Health What To Expect From Counseling a resource from: 515 Highland Street, Morton, IL 61550 v Tel: (309) 263-5536 Fax: (309) 263-6841
3 DRUG REHAB FOR TEENAGERS
4 4 5 5 6 7 8 10 11 12 3 DRUG REHAB FOR TEENAGERS Discovering that a teen is taking drugs or alcohol is worrisome. Parents not only worry about the impact on a child s health, but also the possible impact
Provincial Youth Addictions Treatment Centre Grand Falls Windsor
Provincial Youth Addictions Treatment Centre Grand Falls Windsor CAREGIVER ASSESSMENT FORM Thank you for taking the time to complete this assessment form. The information you provide will assist us in
Describe your current employment, including duties, hours, rate of pay and benefits?
CUSTODY INTAKE Name Address Home phone Business phone Cell phone(s) fax e-mail(s) Social Security # other contacts length of marriage (present; and priors) Describe your educational background Describe
VIRTUAL UNIVERSITY OF PAKISTAN FORMAT OF THE INTERNSHIP REPORT FOR BS Psychology (Clinical Setting)
VIRTUAL UNIVERSITY OF PAKISTAN FORMAT OF THE INTERNSHIP REPORT FOR BS Psychology (Clinical Setting) 1. Title page The title page of the report will include: Clinical Case Studies The name of the internee,
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
How To Protect Your Health Care Information From Disclosure
Thank you for choosing North Valley Christian Counseling. We look forward to working with you. Please take a few minutes to fill out the following forms. We will also take a few moments at the beginning
to Send-Off Your Loved One to Rehab
G O O Y B D to Send-Off Your How Loved One to Rehab O O D B Y E Table of Contents G O O D B Goodbye is Saying Not Easy If a loved one is abusing drugs or alcohol, helping them enter a rehab program is
Discover Your Spiritual Gifts! By Gene Wilkes
Discover Your Spiritual Gifts! By Gene Wilkes Ken Hemphill defines a spiritual gift as an individual manifestation of grace from the Father that enables you to serve Him and thus play a vital role in His
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
REDEMPTIVE GIFTS QUESTIONNAIRE. Directions for completing the questionnaire:
1 REDEMPTIVE GIFTS QUESTIONNAIRE Directions for completing the questionnaire: For each of the statements, think about how you usually function in your organisation. There may be times when you find it
Adult Intake Information
Adult Intake Information Welcome to Eagle s Landing Christian Counseling Center! We know that you have many options for behavioral health care, and we appreciate your choosing our team to assist you. On
Drug Use Among Canadian Professionals: Executive Summary of Final Report
Health Canada Santé Canada Drug Use Among Canadian Professionals: Executive Summary of Final Report Prepared by: Joan M. Brewster, Ph.D., Scientist Addiction Research Foundation of Ontario Published by
WORKSHEET FOR DIVORCE PLEASE FURNISH THE FOLLOWING INFORMATION IN NARRATIVE FORM
WORKSHEET FOR DIVORCE PLEASE FURNISH THE FOLLOWING INFORMATION IN NARRATIVE FORM It is important that your attorney know as much about your case as possible. This includes both the strengths and weaknesses
Application Procedure FIRE School of Ministry
Application Procedure PLEASE READ THIS DOCUMENT IN ITS ENTIRETY BEFORE APPLYING WHEN TO APPLY: accepts students twice per year, at the start of the Fall and Spring semesters. Prospective students should
Name (Partner A): Name (Partner B): Address: Phone number:
Suze Orman - The Ultimate Protection Portfolio What Your Financial Advisor Must Ask You or You Must Ask if the Advisor is You 2003 Suze Orman Revocable Trust Name (Partner A): Name (Partner B): Address:
Cornerstone Christian Counseling, Ministry of First Baptist Church of Louisa
Date: Dr. Shelia Kensinger Jill Robinson Abby Pinson 332 River Bend Road, Louisa, KY 41230 Phone: 606 638 3322 Cornerstone Christian Counseling, Ministry of First Baptist Church of Louisa Client s Name:
THE ABSENT MOTHER. The Psychological and Emotional Consequences of Childhood Abandonment and Neglect. Dr. Judith Arndell Clinical Psychologist
THE ABSENT MOTHER. The Psychological and Emotional Consequences of Childhood Abandonment and Neglect Dr. Judith Arndell Clinical Psychologist The Psychological Parent The object of the child s deepest
Informed Consent for Collaborative Divorce Coach
Informed Consent for Collaborative Divorce Coach Welcome to my Collaborative Divorce Practice. I am committed to helping you achieve your desired outcome during our time together. A Collaborative Divorce
Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist
1 Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist Adult Questionnaire Patient Name: Date: Street Address: City, State: Zip Code: Home Phone: Work Phone: Cell Phone: Best Number to reach
OK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
How To Treat An Addiction
Bridging the Gaps an integrative addiction treatment facility About Us About Us Bridging the Gaps (BTG), an integrative residential addiction treatment facility located in historic Winchester, Virginia,
INITIAL PAPERWORK PACKET YOUTH (14-17)
INITIAL PAPERWORK PACKET YOUTH (14-17) INSTRUCTIONS FOR YOUR FIRST APPOINTMENT: 1. Print this information packet and complete all aspects before your appointment date. Please bring the completed packet
Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No
: Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:
Adoption in Washington State
Adoption in Washington State A Lifelong Developmental Journey DSHS 22-1096(X) (Rev. 1/05) Adoption A Lifelong Developmental Journey Adoption is the permanent, legal transfer of all parental rights from
ADOPTION. The Adoption Law All adoptions filed in the state of Missouri are governed by the same 1123
ADOPTION What is Adoption? Adoption is a legal process that establishes a parent/child relationship between two people who are not otherwise related by blood. There are three sets of participants in an
The Counselor as a Person and as a Professional
Self-Awareness The Counselor as a Person and as a Professional Chapter 2 Psychology 475 Professional Ethics in Addictions Counseling Listen to the audio lecture while viewing these slides Without a high
RELATIONSHIP QUESTIONNAIRE. 1. Can you say there s no jealousy in your relationship? Yes No
Circle either Yes or No to the following questions: RELATIONSHIP QUESTIONNAIRE 1. Can you say there s no jealousy in your relationship? Yes No 2. Is your relationship free of drug and alcohol abuse? Yes
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM. Every child deserves a Forever Family ADOPTIVE HOME APPLICATION
THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM Every child deserves a Forever Family ADOPTIVE HOME APPLICATION The Crossnore School PO Box 249 Crossnore, NC 28616 Phone: (828)733-4305 Fax: 733-1704 Website:
CHARIS PROPERTY MANAGEMENT
CHARIS PROPERTY MANAGEMENT CRIMINAL BACKGROUND CHECKS WILL BE PERFORMED ON ALL APPLICANTS. CONVICTION OF THE FOLLOWING CRIMES WILL MOST OFTEN CONSTITUTE THE AUTOMATIC REJECTION OF TENANCY: murder sale
Family Therapy and Substance Abuse Treatment Post Test
Family Therapy and Substance Abuse Treatment Post Test Following your reading of the course material found in TIP No. 39. Please read the following statements and indicate whether each is true or false.
NORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM. Atty Present?: 9 YES 9 NO Interpreter: 9 YES 9 NO
PROB 1A (ND/CA 11/10) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM THIS SECTION TO BE COMPLETED BY U.S. PROBATION OFFICE Date of Interview:
8006.5:12/87 AMERICAN BAPTIST RESOLUTION CONCERNING ABORTION AND MINISTRY IN THE LOCAL CHURCH
8006.5:12/87 AMERICAN BAPTIST RESOLUTION CONCERNING ABORTION AND MINISTRY IN THE LOCAL CHURCH The General Board of American Baptist Churches in the U.S.A. has solicited and received significant response
City: County: State: Zip:
DATE: BAILEY & GALYEN ATTORNEYS AT LAW Name DOB: Sex: M F Last Name First Middle Maiden Place of birth Country Social Security Number: Drivers License Number: State Address: Apt. # City: County: State:
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY
8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
Georgia Advance Directive for Health Care
Georgia Advance Directive for Health Care In order to have a legal document that expresses your wishes for the health care you want to receive at the end of your life, you should complete a Georgia Advance
YOUTH MINISTRY INTERN Kenilworth Union Church
PAID INTERNSHIP DESCRIPTION YOUTH MINISTRY INTERN PURPOSE For the intern, this is an opportunity to gain practical ministry experience, to work in an atmosphere of personal and professional guidance and
6. What are the possible consequences of divorce for adults?
6. What are the possible consequences of divorce for adults? [I]ndividuals who make the decision to divorce need to be wellinformed about its potential costs to themselves, their partners, and their children.
Changing children s lives
What is adoption? 01 What is adoption? Through adoption you can give a child a permanent, caring home and a sense of belonging, with the love and security of a stable family life guaranteed until they
Drug-Addicted behaviors under Psychodynamic-Perspective
Drug-Addicted behaviors under Psychodynamic-Perspective Mr.Phaitoon Sangpoom Office of the Royal Development Projects Board Introduction Understanding and studying about factors that influence a person
Application for Membership Fishers of Men Ministries
Application for Membership Fishers of Men Ministries Date Interviewer 1. Print Name (Last, First, Middle) 2. Date of Birth,, Month Day Year 3. What is your social security number? 4. What is your driver
Care Programme Approach (CPA)
Care Programme Approach (CPA) The Care Programme Approach (CPA) is the system that is used to organise many people s care from 'secondary mental health services'. This factsheet explains what you should
2. See additional Oral Exam sections on this website area for additional information: http://certbd.org/testing/oral-test-questions/
Addiction Professionals Certification Board, Inc. East Brunswick, New Jersey www.certbd.org fax: 732-249-1559 Directions for the Case Presentation Method and Oral Test Registration 1. You must have an
NLSY79 Young Adult Selected Variables by Survey Year
I. LABOR MARKET EXPERIENCE VARIABLES A. Current labor force and employment status Survey week labor force and employment status Hours worked in survey week Hours per week usually worked Job search activities
General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)
Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose
Pintar Albiston Las Vegas Family Law Attorneys
HOW DOES THE JUDGE DECIDE CUSTODY ISSUES IN NEVADA? In the state of Nevada, parents who are separating or divorcing are encouraged to work together outside of court to determine who should have custody
CHRISTIAN LIFE TRAINING ACADEMY
CHRISTIAN LIFE TRAINING ACADEMY The wise also will hear and increase in learning, and the person of understanding will acquire skill and attain to sound counsel [so that he may be able to steer his course
You will be secure, because there is hope. Job 11:18
You will be secure, because there is hope. Job 11:18 The vision of Acres of Hope is to provide a safe family environment and a healthy living program for women with children that sets the foundation of
PERSONAL RECOVERY PROGRAM INTAKE APPLICATION
A Ministry of Phoenix Rescue Mission PERSONAL RECOVERY PROGRAM INTAKE APPLICATION CLC Intake Application 121211 CLC Page 1 of 6 Attention Intake Coordinator 338 North 15 th Avenue, Phoenix, AZ 85007 Phone:
Chattahoochee Valley Youth Ministry
Volunteer Application Packet To be involved in the Chattahoochee Valley Youth Ministry Much of this material was copied from: Purpose Driven Youth Ministry by Doug Fields. Copyright 1998 by Doug Fields.
5The. Love. Languages
INTRODUCTION 5The Love Languages S I N G L E S E D I T I O N We are about to experience a journey of discovery as we search for understanding regarding one of life s greatest challenges: How can we fulfill
PLANNED TRANSITIONS GUIDING YOU THROUGH LIFE S PASSAGES LIFE S PASSAGES PORTFOLIO
PLANNED TRANSITIONS GUIDING YOU THROUGH LIFE S PASSAGES LIFE S PASSAGES PORTFOLIO 1 Personal History Vital Statistics Date: Name: First Middle Maiden Name Last Address: City County State ZIP Sex: Male
Instructions for_usinq the Counselor Traininq Application IMPORTANT -- PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE LEAVING THIS FACILITY
NAVY DRUG AND ALCOHOL COUNSELOR TRAINING APPLICATION PRIVACY ACT STATEMENT Authority to request this information is derived from 5 U.S.C. 301, E.O. 9397, SECNAVINSST 5300.28B, and OPNAVINST 5350.4B. The
Sexual Behavior and Children: When Is It a Problem and What To Do About It
Sexual Behavior and Children: When Is It a Problem and What To Do About It The Harborview Center for Sexual Assault and Traumatic Stress has services to help families of children with sexual behavior problems.
Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES
COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES The mission of the counselors at Synchronicity Counseling is to offer a holistic, nonjudgmental approach to therapy with an understanding that all human