Firmly Rooted Biblical Counseling

Personal Intake Form

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    General Information


    Marital Status (check all that apply)

    Health Information

    My Health Is

    Are you currently working with any other counselor or therapist?

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

    Religious Background

    Do you pray to God?

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

    How frequently do you read the Bible?

    Briefly answer the following questions:

    Were you referred here by someone?