WELS/ELS Christian Therapist Network Case Study Consult Form 1Personal2History A field marked with a red asterisk is required.Date staffed* MM slash DD slash YYYY Therapist name* First Last E-mail* Client/Patient InformationDo not include client/patient name.Case TitleEnter a short descriptive title of your case study AgeGenderSelect one . . .FemaleMalePrefer not to answerDemographic statusSelect one . . .Child under age 18DivorcedMarriedSinglePrefer not to answerReason for referral Do not include client/patient name in your responses below.History of issuePast psychological/Mental health history or treatmentCurrent stressorsFamily constellation (if applicable)SymptomsRisk assessmentBrief background historyPrevious psychological testingSpiritual issuesTreatment objectivesDSM clinical impressions/Differential diagnosisClinical strategiesAdd Feature photo Drop files here or Select files Accepted file types: jpg, png, Max. file size: 50 MB, Max. files: 1. I have not included client/patient name* Data Privacy & Permission* I AGREE with the terms of the WELS Privacy Policy.NOTE TO EU CITIZENS, RESIDENTS, TOURISTS, AND OTHER PERSONS TEMPORARILY IN THE EU: By submitting this form you consent to any and all information you provide and submit via the site being sent to the United States of America. The United States has not sought nor received a finding of “adequacy” from the European Union under Article 45 of the GDPR. WELS relies on derogations for specific situations as set forth in Article 49 of the GDPR. You are also informed that the United States presently does not have an adequate level of personal data protection as determined by the European Commission’s adequacy decision on October 6, 2015 (case c-362/14) and articulated in the European Union’s General Data Protection Regulation and has not received a similar designation of adequacy by any other foreign data protection authority. You agree to the transfer of your data and personal data to the United States, however, to be used in accordance with WELS Privacy Policy.CAPTCHAThis field is hidden when viewing the formPost Body Δ Christian Therapist Network: Contact us | Privacy policyRef: WELS/ELS Christian Therapist Network Consultation Application