Joy M. Seidner, M. Ed.

Wildwood Office Park

1905 Woodstock Road

Building 500, Suite 5150

Roswell, Georgia 30075

Direct confidential #678-200-9960

Hello!

Below is some basic information about my practice and myself.

  • Masters of Education in Counseling Psychology – Summa Cum Laude,

Georgia State University, Psychological Studies Institute program, 1979.

  • Licensed by the Georgia Christian Counselor’s Association.
  • Personally trained by John and Paula Sandford (authors of

Transformation of the Inner Man).

  • Successful practice over 26 years.
  • Work with adults, couples, and teens.
  • Teach Bible studies, lead retreats.
  • Train teachers and counselors.

Hours:Mondays……....9AM-4:30PM

Wednesdays….11am-7:30 PM

Fridays…….....9AM – 4:30 PM

Fees:1 Hour………..$95

1 ½ Hours…….$125

The ‘hour’ includes 5 minutes for handling administrative

details such as scheduling the next appointment, etc.

Only checks and cash accepted.

I am grateful to God for equipping me to understand and minister to the deep hurting places in people. I look forward to meeting you, getting to know you, and participating in your healing.

Sincerely,

Joy

Joy M. Seidner, M. Ed.

Wildwood Office Park

1905 Woodstock Road

Building 500, Suite 5150

Roswell, Georgia 30075

Direct confidential #678-200-9960

PRECOUNSELING PROFILE

The following comprehensive form, which will become a part of your confidential file, will help me focus most clearly on your areas of concern. Please answer each question fully. If a question does not apply to you, simply write “N/A”. Unless otherwise requested, please bring these forms with you to our first session.

Date:______

  1. Name: ______
  1. Address: ______Phone: ______

City/State:______Zip: ______

  1. Age: ______
  1. Occupation: ______Business Phone: ______
  1. Marital Status: Single ______Married ______Remarried ______Divorced ______Widowed______
  1. Referred by: ______

(Name) (Address)

  1. Education: Circle last year completed

Grade School 1 2 3 4 5 6 7 8 High School 1 2 3 4

College 1 2 3 4 5 6 + Other Training: ______

  1. Note your physical health: Very Good ______Good ______Average ______Declining ______
  1. List significant past illnesses, injuries, handicaps ______

10. Have you used drugs for other than medical purposes? ______

If so, what?______

Religious:

11. Your denominational preference: ______Spouses preference ______

  1. What is your relationship with God? ______
  1. Explain any recent changes in your religious life ______

II. CLINICAL

  1. Have you ever had psychotherapy or counseling? ______If so, when and from whom? ______

______

  1. List any prescribed medication you are presently taking ______

______

3. What is the main problem as you see it?

4. What have you already done about it?

5. What are your goals in coming for counseling?

6. Give a word picture (description) of yourself as you would be described by:

a. Your spouse:

b. Your best friend:

c. Your worst enemy:

d. Yourself:

II. CLINICAL (cont.)

7. Problem Areas

In the following list, place a check mark next to each item, which identifies an area of concern to you. Place two checks by those items, which are most important. (You may add written comments after areas checked).

______Anger/Temper

______Children

______Depression

______Education

______Family problems

______Fatigue

______Fearfulness

______Financial problems

______Headaches

______Inferiority feelings

______Loneliness

______Insomnia

______Marital problems

______Nightmares

______Physical problems

______Pornography

______Problems with social relationships

______Religious/spiritual concerns

______Sexual concerns

______Thoughts of suicide

______Trouble making decisions

______Unable to relax

______Unhappy most of the time

______Use of alcohol

______Use of drugs

______Work

______Worry

______Other ______

(specify)

8. PLEASE COMPLETE THE FOLLOWING

  1. The most important thing to me is ______
  1. I worry about ______
  1. What I do best is ______
  1. I have sometimes felt guilty about ______
  1. I have been criticized for ______
  1. What makes me angry is ______
  1. My biggest mistakes were ______
  1. My job ______
  1. What makes me nervous is ______
  1. My personality would be better if ______
  1. I often felt that my mother ______
  1. Jesus Christ ______
  1. My temper ______
  1. My childhood ______
  1. Prayer is ______
  1. My biggest disappointment ______
  1. To me, sex is ______
  1. I would be better liked if ______
  1. I often felt that my father ______
  1. God to me is ______
  1. My child/children (brothers and sisters) ______
  1. Women are ______
  1. What hurts me most is ______
  1. My biggest problem in life is ______
  1. Men are ______
  1. I am afraid ______
  1. I wish ______
III. GENERAL FAMILY HISTORY
  1. Date and place of birth ______
  1. Mother’s condition during pregnancy (as far as you know) ______

______

  1. Approximately how many times did you family move when you were young? ______
  1. Parents

If separated or divorced, how old were you at the time? ______

Father deceased? ______How old were you at the time? ______

Step-father deceased? ______How old were you at the time? ______

Mother deceased? ______How old were you at the time? ______

Step-mother deceased? ______How old were you at the time? ______

Father remarried when you were age ______You lived with whom? ______

Mother remarried when you were age ______You lived with whom? ______

Until age 18 tell how long you lived with Mother ______Father ______

Step-mother ______Step-father ______Other ______

How did the step-parent relate to you? (kindly, poorly, affectionately, little discipline, etc.)

______

Natural father’s occupation ______

Natural mother’s occupation ______

Step father’s occupation ______

Step mother’s occupation ______

How many times was your father married? ______Your mother? ______

Rate your parent’s marriage: Miserable ______Unhappy ______Average ______

Happy ______Very Happy ______

Their marriage lasted ______years

  1. Give an impression of your home atmosphere
  1. How were you disciplined as a child?

III GENERAL FAMILY HISTORY (CON’T)

  1. Siblings

List your brothers and sisters (indicating stepbrothers and sisters) from oldest to youngest including yourself. Please include any miscarriages or abortions that you know of

NameSexAgeMarital StatusJobDescribe each person

______

______

______

______

______

______

Describe the relationship you have with your brothers and sisters

  1. Past
  1. Present
  1. Brother or sister most like you, in what respect?
  1. Brother or sister most different from you, in what respect?
  1. Who played together?

IV. PARENTAL RELATIONSHIP: FATHER

This denotes the man who took primary responsibility for raising you. If that is a different person from your biological father please note that here ______

  1. As I was growing up, Dad was… (use as many descriptive adjectives as you can)

______

______

______

______

______

  1. I wish my dad

______

______

______

______

______

  1. My dad was… (circle the most appropriate number)

AN UNFAIR AUTHORITYOKFAIR AUTHORITY

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DISTANTOK CLOSE

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STINGY WITH PHYSICAL GOODSOK GENEROUS

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UNAFFECTIONATEOK AFFECTIONATE

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SELF CENTEREDOK ATTENTIVE TO YOU

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CRITICALOK ACCEPTING

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WEAKOK STRONG

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ANGRYOK MERCIFUL

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ABUSIVEOK PROTECTIVE

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  1. His ambition for the children
  1. His relationship to the children
  1. His relationship with my mother
  1. His favorite child, why.
  1. Which child was most like dad, why.
  1. Which child was most different from dad, why?
  1. As a child, I liked about dad
  1. As a child, I disliked about dad

IV. PARENTAL RELATIONSHIP: MOTHER

This denotes the woman who took primary responsibility for raising you. If that is a different person from your biological mother please note that here ______

  1. As I was growing up, Mom was… (use as many descriptive adjectives as you can)

______

______

______

______

______

  1. I wish my mom

______

______

______

______

______

  1. My mom was… (circle the most appropriate number)

AN UNFAIR AUTHORITYOKFAIR AUTHORITY

1234567

DISTANTOK CLOSE

1234567

STINGY WITH PHYSICAL GOODSOK GENEROUS

1234567

UNAFFECTIONATEOK AFFECTIONATE

1234567

SELF CENTEREDOK ATTENTIVE TO YOU

1234567

CRITICALOK ACCEPTING

1234567

WEAKOK STRONG

1234567

ANGRYOK MERCIFUL

1234567

ABUSIVEOK PROTECTIVE

1234567

  1. Her ambition for the children
  1. Her relationship to the children
  1. Her relationship to my father
  1. Her favorite child, why
  1. Which child was most like mom, why.
  1. Which child was most different from mom, why?
  1. As a child, I liked about mom
  1. As a child, I disliked about mom

V. MARITAL INFORMATION

  1. Name of spouse: ______Age: ______Religion: ______
  1. Occupation: ______Business Phone: ______
  1. Is your spouse willing to come for counseling? Yes ______No ______Maybe ______
  1. Have either of you ever filed for divorce? Yes ______If Yes, When ______No ______
  1. Date of this marriage ______Ages when married: You ______Spouse ______
  1. Give brief information about any previous marriages ______

______

Broken by divorce ______Death ______

  1. Areas in your marriage that need improvement: (Circle) Financial Sexual Spiritual Husband’s Leadership Wife’s Role Child Rearing Other: ______

Please Describe:

  1. What I liked the first few years
  1. What my mate liked the first few years
  1. What I disliked the first few years
  1. What my mate disliked the first few years
  1. What I have liked/disliked the last few years
  1. What my mate has liked/disliked the last few years
  1. In what areas are you most compatible?
  1. In what areas is there incompatibility?

VI. INFORMATION ABOUT CHILDREN

Please list names of your children from oldest to youngest. State if any of these children are from a previous marriage or adopted. Also, in birth order please include any miscarriages or abortions.

NameSexAgeMarital StatusJob Description

______

______

______

______

______

______

  1. With which child do you get along the best?
  1. With which child do you have the most challenges?
  1. Please state if there are specific concerns about any child
VI. SEXUAL HISTORY
  1. Parental attitudes toward sex (i.e. was there sex instruction or discussion in the home?)
  1. When and how did you gain your first knowledge of sex?
  1. When did you first become aware of your sexual impulses?
  1. Did you ever experience any anxieties or guilt feelings or trauma arising out of sexual experience with the opposite sex? If yes, please explain.
  1. Did you ever experience any anxieties or guilt feelings or trauma arising out of sexual experience with the same sex? If yes, please explain.
  1. Is there any question or concern you have about sexual experiences past or present; or your sexual identity?