Personal Information Form

Name:

Email:

Phone:

Address:

Who referred to our ministry? Or how did you find us?

Age:

Sex:

Marital Status:
—Please choose an option—SingleDatingEngagedMarriedSeparatedDivorcedWidowed

Education (highest completed):

What is your occupation and place of employment:

What brings you to discipleship counseling?

What difficulty or problem are you facing?

What have you done about it?

How have you contributed to the problem?

Why have you sought biblical counseling? What are your expectations from counseling?

Spouse

Name:

Email:

Phone:

Age:

Education (highest completed):

What is your spouses occupation and place of employment?

Date of Marriage:

Length of Dating and or engagement:

Describe any previous or current conversations about separation or divorce:

Were you or your spouse previously married?

Children:

Include the following answers: Name, Age, Sex, Living (Y/N), Step-Child (Y/N):

Describe any conflict in parenting style:

Birth Family

Are either sets of parents actively involved in your family dynamics?

List your siblings and their ages:

Health

Describe your overall health:

Date and report of last medical exam:

List current medication(s) and dosage:

Have you ever used recreational drugs? (Y/N):

Describe your present use of alcoholic beverages:

Describe your present use of caffeine beverages:

Describe your normal sleep schedule/ pattern:

Describe your typical response when you are angered:

Describe any police arrests:

Describe the pattern of your screen time (TV, computer, video gaming, etc.):

What do you like to do in your down time?

Describe any interpersonal problems on the job?

Describe any time spent with a psychiatrist or psychologist (include the name and address of the organization):

If pertinent may your counselor write for social, psychiatric, or other medical records?

Women Only:

Describe any menstrual difficulties including tension, tendency to cry or other symptoms prior to your cycle:

Spiritual

Name and web address of the church you are attending:

Are you a member of this church?

Pastor’s name and contact information:

Describe your Church participation:

Do you and your spouse share the same church attendance?

Briefly describe your belief in God:

Briefly describe your belief in Christ:

Describe your pattern of Bible reading:

How often do you pray and what do you pray for the most?:

Describe your pattern of serving the body of Christ and or participation in ministry:

Describe any recent significant changes in your spiritual life:

Have you shared the problems for which you are seeking counseling with your pastor and/or other mature members of your church?

Please describe any recent loss of someone close to you:

From the following name your top three areas of concern; anger, anxiety, apathy, appetite, bitterness, change in lifestyle, children, communication, conflict, control, deception, decision making, depression, disciplined living, disorganization, discouragement, drunkenness, envy, fear, finances, gluttony, guilt, health, homosexuality, impotence, in-laws, laziness, loneliness, lust marriage, memory, moodiness, overwhelmed, perfectionism, pornography, procrastination, rebellion, sexual immorality, sex within the marriage, sleep, spouse abuse, time usage, weary, other:

List the people you are presently in conflict with:

Complete the following sentences

I am

I like

I am happy

I am unhappy

God is

A happy home

I want

I dislike

When I sin

Jesus Christ is

I have

When someone criticizes me

When I don’t get my way

The Holy Spirit is

I resent

I feel guilty

I would like to change

The Bible

I pray

Describe anything we should know about you that we did not ask: