Biblical Counseling Intake Form for Minors (Under 18)

Please fill out this form and click submit.

Who is filling out this form?

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Please select one option.

Parent/Guardian on behalf of child/teen Child/Teenager Parent/Guardian and Child/Teen are filling out the form together

Personal Information

Name

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Gender

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Please select one option.

Male Female

Address

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Birthdate

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Current grade level

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Phone (of primary contact)

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Email (of primary contact)

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This address will receive a confirmation email

Family

Parent 1

Name

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Relationship to child

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Phone

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Parent 2

Name

Relationship to child

Phone

Have parents ever been separated or divorced?

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Please select one option.

yes no

Are parents currently married?

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Please list household members. If the child lives in multiple households, please explain:

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If the child is raised by someone other than parents, please explain:

Spiritual Life (Please allow child/teen to answer as much as possible)

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?

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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?

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:

Current medications:

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 consume drinks with caffeine? If so, what kind of drinks, and how much do you consume daily?

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Do you drink alcohol?

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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 (child and/or parent) done on your own about this?

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What are your (child and/or parent)expectations for counseling? What are you (child and/or parent) 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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