Stacy Finch, RCC Life Coach and British Columbia Registered Clinical Counsellor #20192www.stacyfinch.comstacy@stacyfinch.com RM_StatsEmail *First NameLast NameGenderAddressCityState or ProvinceZip or Postal CodeCountryHome PhoneMay I leave a detailed message?Work PhoneMay I leave a detailed message?Cell PhoneMay I leave a detailed message?Date of BirthWhat is your occupation?Marital StatusPartner’s NamePartner’s GenderPartner’s Address (if different)CityState or ProvinceZip or Postal CodeCountryPartner’s Date of BirthPartner’s OccupationWhat do you want to talk about in counseling?How long has the problem been going on?Is it getting better or worse now?What makes it better or worse?Would anyone else be involved in your counselling?Are you currently in treatment for any medical problems, including taking medication of any type? Please explain.Is there a concern about alcohol, drug abuse, or overuse of non-prescribed drugs? Please explain.Is there a concern about violence in your life today? Either from you or towards you? Please explain.How concerned are you about violence on a scale of 1 to 10 with 10 being the worst.Is there a concern about suicide? Please explain.How concerned are you about suicide on a scale from 1 to 10 with 10 being the worst?Have you had any counseling before?Where did you go?What was it concerning?Is there anything else that you would want the counselor to know before your appointment?How did you hear about Stacy Finch? Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.