Biblical Counseling

Please fill out the counseling intake form. We will respond in a few days. Once a weekly appointment has been set up, please be on time to each session and do not cancel appointments unless it is an absolute emergency. Please bring your Bible to the counseling sessions. If you do not own one, please let us know!

Name

Phone Number

Email Address

Address

City, State, ZIP

Occupation

Employer

Birth Date (MM/DD/YYYY)

Gender

Age

Marital Status

Education

Degree

Other Training

Hobbies

Referred to Us By

Relationship

If you were raised by anyone other than your parents, briefly explain:

How many siblings do you have?

Spouse's Name

Spouse's Phone

Spouse's Address

Spouse's Age

Spouse's Occupation

Spouse's Religion

Spouse's Education

Does your spouse know you are coming for counseling?YesNo

Is your spouse willing to come to counseling?YesNo

Have you ever been separated?YesNo

If yes, when?

How many years have you been married?

Give brief information about any previous marriages (if applicable)

Names of Children

Ages of children

Have you ever dealt with severe emotional struggles in your past?YesNo

Have you ever been to any therapy or counseling before?YesNo

If Yes, please list the counselor or therapist and approximate dates:

What was the result of your counseling?

List any fears you have:

Have you ever been arrested?YesNo

Reason for arrest:

Rate your health:Very GoodGoodAverageDeclining

Approximately how many hours of sleep do you get each night?

Have you had any weight changes recently? Please describe.

Do you have any chronic medical conditions? Please list and describe below.

When was the last time you were seen by a doctor?

Are you taking any prescription medications? If so, please list below:

How much alcohol do you consume? DailyWeeklyOccasionallyVery little or never

Have you used illegal or excessive prescription drugs in the past five years?YesNoNot Sure

What church did you attend as a child (if any)?

What church do you attend now (if any)

Do you desire for us to contact your pastor for background information? YesNo

Do you believe in God?YesNo

Do you pray to God?YesNo

Are you a Christian?YesNo

Have you come to a place in your spiritual life where you can say that you know for certain that if you were to die you would go to heaven? YesNo

How often do you read the Bible?OftenOccasionallyNever

Does your family read the Bible and pray together? OftenOccasionallyNever

Religious background of spouse?

If you were to die and God asked you, "Why should I let you into heaven?" What would you say?

Explain any recent changes in your religious/spiritual life, if any:

How do you describe the issues with which you are struggling?

What have you tried to do about it?

How do you hope counseling might help? (What are your expectations in coming here?)

What brings you here at this time? Did any recent event cause you to schedule an appointment now?

Is there any other information you think we should know to help you?

Have you completed the form in its entirety?Yes, I've completed the form and am ready to submit.

Thank you! Your intake form has been received!

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Biblical Counseling

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