Stacy Finch, RCC Email* First Name Last Name Gender Address City State or Province Zip or Postal Code Country Home Phone May I leave a detailed message? Work Phone May I leave a detailed message? Cell Phone May I leave a detailed message? Date of Birth What is your occupation? Marital Status Partner’s Name Partner’s Gender Partner’s Address (if different) City State or Province Zip or Postal Code Country Partner’s Date of Birth Partner’s Occupation What 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?
