COUNSELING INTAKE FORM

PERSONAL HISTORY/PROBLEM EVALUATION

BASIC INFORMATION ABOUT THE PROBLEM

Date:

First Name

Last Name

Phone Number

Address 1

Address 2

Country

City

State

Zip/Postal Code

OCCUPATION:

BUSINESS PHONE #:

GENDER
Male
Female

BIRTH DATE:

AGE:

Email

EDUCATION: Last Grade Completed (Prior to college)

Other Education (List type and years)

RECOMMENDED BY:

NAME OF SPOUSE:

SPOUSE'S OCCUPATION:

SPOUSE'S ADDRESS (If different from yours):

THE BASIC PROBLEM AS YOU UNDERSTAND IT:

Briefly complete the following:

1. PLEASE DESCRIBE THE CURRENT PROBLEM:

2. WHAT HAVE YOU DONE ABOUT IT?:

3. WHAT HELP ARE YOU SEEKING?:

4. WHAT LED YOU TO SEEK HELP NOW?:

DETAILED INFORMATION RELATED TO THE PROBLEM

Information about spiritual life:

DENOMINATIONAL PREFERENCE:

CHURCH NAME:

CHURCH ADDRESS:

PASTOR'S NAME:

CHURCH ATTENDANCE: Frequency of attendance

Times Per Month

WHAT ARE YOU LEARNING FROM THE SERMONS/MESSAGES/BIBLE STUDIES AT YOUR CHURCH?:

PLEASE LIST MINISTRY INVOLVEMENT:

CHURCH ATTENDED IN CHILDHOOD:

HAVE YOU BEEN BAPTIZED?
Yes
No

WHEN?

IF MARRIED, RELIGIOUS BACKGROUND OF SPOUSE:

(ONLY IF APPLICABLE) SPOUSE'S CHURCH ATTENDANCE:

Spouse's church name:

(Frequency of attendance, times per month):

DO YOU PRAY TO GOD?
Never
Occasionally
Often

WHAT DO YOU PRAY ABOUT?

HAVE YOU COME TO A PLACE IN YOUR SPIRITUAL LIFE WHERE YOU KNOW WITH CERTAINTY THAT IF YOU WERE TO DIE TONIGHT YOU WOULD GO TO HEAVEN?
Yes
No
Uncertain

IF YES, WHAT IS YOUR BASIS FOR ANSWERING THE ABOVE QUESTIONS YOU DID?

HAVE YOU RECEIVED JESUS CHRIST PERSONALLY AS YOUR SAVIOR?
Yes
No
Uncertain
Don't Know What You Mean

IF YES, HOW DO YOU KNOW THAT JESUS CHRIST IS YOUR SAVIOR?

IF YOU HAVE RECEIVED CHRIST AS YOUR SAVIOR, WHAT CHANGES TOOK PLACE IN YOUR LIFE WHEN YOU BECAME A BELIEVER?

IF YOU HAVE RECEIVED CHRIST AS YOUR SAVIOR, HAVE YOU TOLD HOUSEHOLD/FAMILY MEMBERS ABOUT RECEIVING JESUS AS YOUR SAVIOR?
Yes
No

WHOM HAVE YOU TOLD?

DO YOU READ THE BIBLE?
Never
Occasionally
Often

How often?

DO YOU HAVE PERSONAL DEVOTIONS?
Never
Occasionally
Often

How often?

DESCRIBE YOUR PERSONAL DEVOTIONS:

DO YOU HAVE FAMILY DEVOTIONS?
Never
Occasionally
Often

How often?

DESCRIBE YOUR FAMILY DEVOTIONS:

EXPLAIN ANY RECENT CHANGES IN YOUR SPIRITUAL LIFE:

INFORMATION ABOUT PRIOR COUNSELING

HAVE YOU HAD ANY COUNSELING BEFORE?
Yes
No

COUNSELOR NAME(S)

DATES: (From - To)

MEDICATION PRESCRIBED

OUTCOME

INFORMATION ABOUT PERSONAL HABITS AND HEALTH

APPROXIMATELY HOW MANY HOURS OF SLEEP DO YOU GET EACH NIGHT?

WHEN DO YOU NORMALLY:

go to bed?

fall asleep?

wake up?

get out of bed?

IS THERE A LENGTH OF TIME BETWEEN YOUR GOING TO BED AND FALLING ASLEEP, WHAT DO YOU DO DURING THAT TIME?

DESCRIBE ANY CHANGES IN EATING HABITS:

DATE OF LAST MEDICAL EXAMINATION:

RESULTS:

ARE YOU PRESENTLY TAKING MEDICATIONS?
Yes
No

WHAT?

DOSAGE?

FOR WHAT REASON DO YOU TAKE THIS MEDICATION?

HAVE YOU USED DRUGS FOR OTHER THAN MEDICAL PURPOSES?
Yes
No

WHEN?

WHAT?

AMOUNTS/DOSAGES?

DO YOU DRINK ALCOHOLIC BEVERAGES?
Yes
No

WHEN?

HOW MUCH?

MARRIAGE AND FAMILY INFORMATION:

NAME OF SPOUSE:

ADDRESS:

PHONE NUMBER #:

OCCUPATION:

BUSINESS PHONE #:

YOUR SPOUSE'S AGE:

EDUCATION (In years):

RELIGION:

IS YOUR SPOUSE WILLING TO COME WITH YOU?
Yes
No
Have not asked yet
Not certain

ARE YOU CURRENTLY SEPERATED?
Yes
No

Since When?

HAVE YOU EVER BEEN SEPERATED IN THE PAST?
Yes
No

Number of times

HAS EITHER OF YOU EVER FILED FOR DIVORCE?
Yes
No

When?

Who?

DATE OF MARRIAGE:

YOUR AGES WHEN MARRIED: (Husband)

(Wife)

HOW LONG DID YOU KNOW YOUR SPOUSE BEFORE MARRIAGE?

LENGTH OF STEADY DATING WITH SPOUSE:

LENGTH OF ENGAGEMENT:

HAVE YOU BEEN MARIED BEFORE?
Yes
No

IF YES, HOW MANY TIME? (Husband)

(Wife)

IF YOU WERE MARRIED BEFORE, HOW DID THE MARRIAGE END?

CHILDREN'S NAMES:

AGES:

GENDER:

LIVING?
Yes
No

EDUCATION IN YEARS:

MARITAL STATUS:

CHECK THIS COLUMN IF CHILD IS WITH PREVIOUS MARRIAGE
Previous Marriage

IF YOU WERE REARED BY ANYONE OTHER THAN YOUR OWN PARENTS. BRIEFLY EXPLAIN:

NUMBER OF OLDER (Brothers)

(Sisters)

NUMBER OF YOUNGER (Brothers)

(Sisters)