Biblical Counseling Intake Form

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Personal Information

Name

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Email

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This address will receive a confirmation email

Phone

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Address

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Birthdate

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Relationships & Family

Marital Status

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Please select one option.

Single Engaged Married

Name of spouse, fiance, or boy/girlfriend

Have you ever been divorced?

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Please select one option.

yes no

Please list your child(ren) and their age(s)

Spiritual Life

Do you believe in God?

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Please select one option.

Yes No I'm not sure

Would you call yourself a Christian?

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Please select one option.

Yes No i'm not sure

Have you been baptized?

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Please select one option.

Yes No i'm not sure

Do you pray? If so, how often?

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Please select one option.

I do not pray. I occasionally pray. I pray often.

Do you read the Bible? If so, how often?

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Please select one option.

I do not read the Bible. I occasionally read the Bible. I read the Bible often.

Do you attend church? If so, how often?

*

Please select one option.

I do not attend church. I attend church occasionally. I attend church semi-regularly. I attend church weekly.

What church do you currently attend?

How are you involved within the church?

Have there been any recent changes in your spiritual life and/or relationship with Jesus Christ? Please explain:

Health

Please list any important illnesses, injuries, chronic conditions, or handicaps:

Do you currently take any medications?

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Do you exercise or participate in physical activity? If so, what kind of exercise/activity do you participate in, and how often?

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Do you drink alcohol? If so, how often?

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Do you drink coffee/tea? If so, how often?

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Do you drink sodas? If so, how often?

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How much caffeine do you consume daily?

Do you smoke or consume any tobacco products? If so, how often?

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Have you ever used drugs for non-medicinal purposes?

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How many hours of sleep do you average each night? Is this sleep restful?

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Additional Information

Have you ever met with a counselor, psychologist, or psychiatrist? If so please explain:

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What problem, challenge, or circumstance are you facing? What are you seeking counsel for?

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What have you done on your own about this?

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What are your expectations for counseling? What are you hoping to get out of counseling?

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Is there any other information you would like to share?

Description

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