In Need of Biblical Counseling? Fill out the form below to learn how we can help Step 1 of 7 14% Personal IdentificationName First Last Birth Date MM slash DD slash YYYY PhoneEmail Age Sex Referred By Marital Status Single Engaged Married Separated Divorced Widowed Address Street Address ZIP / Postal Code Education (last year completed) Employer Position Years PhoneWeekly Work/School Hours Marriage and FamilySpouse Birth Date MM slash DD slash YYYY Age Occupation How Long Employed? Home PhoneWork PhoneDate of Marriage MM slash DD slash YYYY Length of Dating Give a brief statement of circumstances of meeting and datingHave either of you been previously married, and to whom? Have you ever been separated? Have you ever filed for divorce? List all childrenFirst NameAgeSexLivingYear Ed.Step Child Add RemoveParents still married Parents living Parents live locally Describe relationship to your fatherDescribe relationship to your motherNumber of sibling(s) Your sibling order Do you or did you live with anyone other than parents? HealthDescribe your overall health Do you have any chronic conditions, important illnesses, injuries and/or handicaps?Date of last medical exam MM slash DD slash YYYY Report Do you have a family doctor or physician you see regularly Current medication(s) and dosageIf you have ever used drugs for anything other than medical purposes, please explainHave you ever been arrested? If you drink alcoholic beverages, how often and how much? If you drink coffee, how often and how much? If you drink other caffeinated drinks, how often and how much? If you use tobacco, what type, how much, and how often?Describe your normal sleeping scheduleIf you've ever had interpersonal problems on the job, please describeIf you've ever had a severe emotional upset, please describeIf you've ever seen a psychiatrist or counselor, please describeAre you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records? SpiritualDenominational preference Church attending Member Pastor's name Pastor's Phone NumberChurch attendance per month Do you believe in God? Do you pray? Would you say you are a Christian OR in the process of becoming a Christian? Have you ever been baptized? How often do you read the Bible? Are you involved in ministry? If you have ever been discipled, please describeExplain any recent changes in your religous lifeWhat are the three biggest positive influences on your spiritual life?What are the three biggest negative influences on your spiritual life?If you have shared the problems for which you are seeking counseling with your pastor and/or any other mature members of your church, please write down their names. If you haven't, please describe any concerns you have about doing so. Women OnlyHave you had any menstrual difficulties? If you experience tension, tendency to cry, other symptoms prior to your cycle, please explainIs your husband willing to come for counseling? Is your husband in favor of your coming, and if not, please explain Problem Severity: Please rate how these items impact your life(blank)= no significant impact; 1= mild impact; 2 = moderate impact; 3 = severe impactPlease rate how much these items impact your lifeN/A123AngerAnxietyApathyAppetiteBitternessChange in lifestyleChildrenCommunicationConflict (fights)ControlDeceptionDecision MakingDepressionDisciplined LivingDisorganizationDiscouraged/DowncastDrunkennessEnvyFearFinancesGluttonyGuiltHealthHomosexualityImpotenceIn-lawsLazinessLonelinessLustMarriageMemoryMoodinessOverwhelmedPerfectionismPornographyProcrastinationRebellionSexual ImmoralitySex (in marriage)SleepSpouse AbuseTime UsageWearyOther Briefly Answer The Following QuestionsWhy have you sought counseling? What difficulties are you facing?What are your expectations from counseling?What are your expectations from counseling?Is there any other information that we should know? Δ
