1. Why are you here?
2. What is the need?
3. What do you want us to do?
4. What have you tried already?
5. Why hasn't that worked?
6. Has anything worked?
7. What kind of support do you have?
8. What difference would it make if we didn't do anything?
9. What is the most cost effective way to proceed?
10. What resources do we have to help?
11. What kind of time are we looking at?
12. What kind of money is this going to take?
13. Are the parties ready to do something at this time?
14. What kind of plan is this going to require?
15. Who is going to do what?
16. Who has the responsibility to do what?
17. Do all the people want to do this?
18. Is there an easier way?
19. Who do we need to call/contact first?
20. What is our next step?
21. What additional information do I need to collect/give?
• Consent for Treatment _____
• Releases of Information _____
• Patient Agreement _____
• Emergency Checklist _____
• Referral Guidelines_____
• Quick Test_____
• Follow up Session_____
• Fee Information_____
• Business Card_____
• Brouchure_____

1. Is this person a danger to themselves or others? If yes, please explain.
2. Do they have a plan to harm or injure them self or someone else? If yes, please explain.
3. Do you suspect child abuse or neglect? If yes, please explain.
4. Is there a threat of domestic violence or elder abuse? If yes, please explain. 
5.  If you have marked yes to any of the above what action including notifying the appropriate authorities are you taking?

Check all that apply:

1. I need individual help   yes___ no___
2. We need help for our marriage   yes___ no___
3. We need help with our kids    yes___ no___
4. I would like my kid(s) to be helped    yes___ no___
5. I need help with my family   yes___ no___
6. I need help with my work    yes___ no___
7. I would like to know God's will for my life   yes___ no___
8. I am struggling to know how to use my spiritual gifts   yes___ no___
9. I would like help in reconciling with someone    yes___ no___
10. I have been a victim of abuse or neglect   yes___ no___
11. I would like to have someone mentor or disciple me    yes___ no___
12. It would help me if someone did an intervention in my life   yes___ no___
13. I am having trouble sleeping  yes___ no___
14. I am having trouble eating   yes___ no___
15. I don't feel safe   yes___ no___
16. I am afraid of what I might do   yes___ no___
17. I need help financially   yes___ no___
18. It is hard for me to concentrate right now    yes___ no___
19. I feel anxious most of the time   yes___ no___
20. I feel depressed most of the time    yes___ no___

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