Religious & Spiritual Counseling Intake Form

Personal Information

Please provide your basic contact information.

🔒

Confidentiality NoticeAll information provided is confidential and will only be used for religious and spiritual counseling purposes in accordance with Islamic ethics (amanah) and applicable laws.

Full Name *

Date of Birth *

Age *

Gender *

Marital Status *

Phone Number *

Email Address *

Address

Emergency Contact

Please provide an emergency contact.

Emergency Contact Name *

Relationship *

Phone Number *

Religious & Spiritual Background

These questions help our counselor better understand your spiritual circumstances.

Current level of religious practice *

Do you perform the five daily prayers? *

Qur'an engagement *

What spiritual challenges are you currently facing?

Reason for seeking religious & spiritual counseling *

Anxiety / Stress Depression / Sadness Family or marital issues Faith-related doubts Anger management Trauma / grief Addiction / harmful habits Identity or life direction Other

Briefly describe your situation *

Physical & Mental Health History

This information helps us determine whether additional professional support may also be appropriate.

Have you been diagnosed with any mental health conditions? *

If yes, please explain

Are you currently seeing a therapist, psychiatrist, or counselor? *

Are you currently taking any medications? *

If yes, please list

Counseling Expectations

Please tell us what you hope to accomplish.

What are your goals for religious & spiritual counseling? *

Are you seeking: *

Consent & Agreement

Please review the following information carefully.

I agree to the terms described above. *

Review & Submit

Please verify your information before submitting.

Personal Information

Emergency Contact

Religious & Spiritual Background

Physical & Mental Health History

Counseling Expectations

Consent & Agreement

Review & Submit

ABOUT US

EDUCATIONAL PROGRAMS

SERVICES

FACILITY

MEDIA