Horizons Unlimited, Inc.

IMPORTANT NOTE:

We are licensed professional counselors and everything you tell us will be held in strict confidence, in keeping with the strict ethical code of professional counselors. We cannot divulge any information about you without written authorization from you.

If you have any questions regarding this form or our services
please do not hesitate to contact us.

Personal Information:


First Name	Middle Name	Last Name

City	State/Province	Zip Code
Street Address
Address cont. - (Apt., Suite, etc..)

Country

E-mail Address	Home Phone	Work Phone	Mobile Phone

Date Of Birth	Sex	Birth Place

Citizen Of:

Language(s) Spoken

Language(s) Read

Are You A Student?

Yes No

If Yes....

What is your school & major?

Are You Working?

Yes No

If Yes....

What is your occupation?

How would you rate your job satisfaction level?

Describe what type of assistance you think you need?

Enclose a chronological work and education history. Please include all work and volunteer experience. Do not be brief, as we want to learn about your background, so that we may better meet your needs.

Describe your educational background in terms of subjects you liked and disliked. Did you like your major and why did you choose it?

What were your plans upon graduation?
Describe what type of assistance you think you need?

Describe each paid or unpaid work in terms of the activities you liked and those you disliked. Start with your first position and work to the present.

Explain any work problems and situations including why you left a job and took the next.

Describe your past or current activities. Include civic, community, hobbies, sports, readings (what type of books) and anything else that sheds light on what you do in your free time.

What activities would you like to do?

Explain any factors which have hindered you from doing what you wanted to do. For example, family, economic, geographic, psychological, health. Describe these issues in depth.

Have you taken career or counseling related tests, exercises or workshop materials?

Yes No

If Yes....

Is any of this type of material available for review by Horizons Unlimited Inc?

Yes No

Any additional comments or questions? Please include a fax number if you have one.

When is the best time to contact you?

Where is the best place to contact you?