Personal Intake Form

General Information

Name:

Date:

Gender:MaleFemale

Date Of Birth:

Address:

Phone Number

Email:

Occupation:

Emergency Contact:

Marital Status (check all that apply)SingleDatingEngagedMarriedDivorcedSeparatedWidowedRemarriedLiving together and unmarried

Health Information

My Health Is Very goodGoodAverageLess than averagePoor

Current Health Issues:

All current medications (prescription and over-the-counter).

Are you currently working with any other counselor or therapist?YesNo

Have you ever participated in counseling or therapy in the past?YesNo

Religious Background

What religion do you associate with?

Describe your current involvement, if any:

Previous involvement in any other religious groups:

Describe your understanding of God:

% Level of confidence in God:

Do you pray to God?NeverOccasionallyOften

Are you forgiven by God? Would you go to Heaven if you died?YesNoNot sure

How frequently do you read the Bible?NeverOccasionallyOften

Do you have a relationship with Jesus Christ? If so, how did this relationship come about?

Please explain any recent changes in your religious life:

Briefly answer the following questions:

What brings you to counseling? Please write a quick summary of your main concerns.

What have you already done about these concerns? What have been the results?

What are your expectations and goals in receiving biblical counseling?

Is there any other information that we should know?

Were you referred here by someone?YesNo

Name and relationship:

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