1020 Barber Creek Drive, Suite 203

Watkinsville, GA 30677
706.543.7012

Angel H. Davis, LCSW, BCPCC

Christian Psychotherapist

Personal Information Form

Confidential

Full Name: ________________________________ Todays Date: _________________

Date of Birth: ____________________ Social Security #: ________________________
Address: ________________________________________________________________
City: _________________________ State: ______________ Zip: __________________
Phone: Home: ________________ Work: ________________ Cell: ________________
Email address: ___________________________________________________________
Referred by: _____________________________________________________________
Name of Church: ______________________ Denomination: ______________________
Occupation: ____________________________________________
Degree(s): Grades Completed: ____ Bachelors:____ Masters:____ Other: _________
Spouses Name: __________________________________________________________
Number of children: _______ Name(s) and age(s):_______________________________
Have you been in counseling? If yes, please provide details.________________________
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Briefly describe what brings you here.
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Check the issues that pertain to you: rate degree of stress/urgency for applicable areas,
1 (low) to 5 (high).
___Depression
___Marital Problem
___Drug Addictions
___Eating Disorder
___Grief/Loss
___Occult Oppression
___Workaholism
___Unforgiveness/Bitterness

___Chronic Illness
___Occult
___Insomnia
___Alcoholism
___Low Self-Esteem
___Career Decision
___Financial Crisis
___Excessive Anxiety/Fear

___Sexual Identity Issues

___Anger
___Physical Abuse
___Sexual Abuse
___Emotional Abuse
___Relationships
___Loneliness
___Spiritual Issues

Other: __________________________________________________________________
Are you under a doctors care? _____ If yes, Doctors Name_______________________
Please share what you are being treated for and any medications you are currently taking.
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In Case of Emergency, who would you like to be contacted?
Name/Relationship__________________________________Phone:_________________