Health Ministries : Nepean Seventh-day Adventist® Church Nepean ON

Name

Address

Phone

Email

Age under 18 18 - 30 30 - 55 over 55

Gender Male Female

Marital Status Single Married Widowed Separated/Divorced

Religious Affiliation:

Have you previously been diagnosed with any mental illness? Check all that apply: Depression Panic Attacks Obsessive Compulsive Disorder Bi-Polar Disorder Schizophrenia Other No diagnosis

Are you currently being treated by a physician or counselor? Yes No

Have you ever attempted suicide? Yes No

If yes, how long ago?

Are you considering suicide now? Yes No

Emergency Contact

Emergency Contact Phone

Please acknowledge your consent: I recognize this is a mental health education program and is not a substitute for physicians, professional counselors, or mental health providers. I understand that attending this program does not establish a physician-patient relationship.

Signature (Type name)

Date

Nepean Seventh-day Adventist^® Church

Health Ministries

COPING WITH DEPRESSION

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