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Counselee Information
First Name:
Last Name:
Middle Initial : 		Gender:
Age:
 		Social Security Number:
 Marital Status:
S M
D W
Address:
 		Housing: (Check one)
Own   Rent   On Base   With Family
City:
 		State:
 		Zip:
 		Number Living in Household:

Security Verification

Home Phone:
 		Birth date:
Facsimile:
 		Mother's Maiden Name:
E-mail:
 		Occupation:
Employer:
 		How Long:
Are you currently working?
 		Work Phone:

Spouse Information
First Name:
Last Name:
Middle Initial : 		Occupation:
 Birth date:
Social Security Number:
 		Employer:
 How Long:
Are debts in both names?
 Work Phone:
How are you paid? (Check one)  Weekly    Biweekly    Twice Monthly   Monthly

How is your spouse paid? (Check one)  Weekly    Biweekly    Twice Monthly Monthly
Are you currently involved in any of the following?   Lawsuits    Garnishments    Back Taxes
Do you attend a church?    Yes    No   If "yes" which one?  
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