Biblical Counseling Application

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Please complete ALL sections completely, accurately, and honestly. Do not leave any item unanswered (if not applicable, write N/A). When completed, please submit. You will receive an email confirmation along with a copy of the information you provided. Once your information is received, our Biblical Counseling Leadership Team, Pastors and/or Elders will meet to prayerfully discern and decide which of our counselors to pair with you. One of our team members will then contact you within 5-7 business days to schedule your first appointment with your biblical counselor.

Identification Information

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Texting(Required)

Email(Required)

Gender(Required)

Marital Status(Required)

Educational Level(Required)

Employer(Required)

Work Schedule(Required)

Referred By(Required)

Reason for Seeking Biblical Counseling

Why do you desire to meet with a biblical counselor?(Required)

How long has this issue existed?(Required)

Were there any significant events occuring in your life/family's life when this issue began?(Required)

Who have you spoken to regarding this issue and what has happened as a result?(Required)

What have YOU done about this issue personally?(Required)

How would things be different for you if the issue were remedied?(Required)

What are your expectations in coming to counseling? How do you think we can help you? What results are you expecting in coming here for biblical counseling?(Required)

In what way(s) have YOU contributed to the problem personally?(Required)

Marriage and Family

How many siblings do you have?(Required)

What number are you in the order of your siblings?(Required)

What is your parents' marital status?(Required)

Do you have children?(Required)

Spouse Information

Spouse

First Last

Phone

Texting Preference

Address

Street Address City State ZIP Code

Spouse's Email

Spouse's Educational Level(Required)

Spouse's Employer

Spouse's Work Schedule

Marriage Date

MM slash DD slash YYYY

Age When Married

How many siblings does your spouse have?

Where is your spouse in the order of his/her siblings?

What is your spouse's parents' marital status?

Length of acquaintance before committing to exclusively dating?

Length of exclusive dating and/or engagement before marriage?

Is your spouse willing to come for counseling?

Have you ever been separated from your spouse?

If yes, for how long and when?

Have either of you ever filed for divorce?

If yes, when/date?

Give a brief description of any previous marriage(s):

Parenting

Children

Add as many rows as necessary

Name

Age

Gender

Education/Grade

Marital Status

PM* (check if from previous marriage)

What type of instruction in Christian living is given in your home and by whom?

Who does the disciplining in your home?

For what behaviors are your children disciplined?

What methods of discipline are currently being used?

How do you and your family members communicate you love each other?

Personality

Check any of the following words that best describe you now:

Personality(Required)

Active

Ambitious

Calm

Compulsive

Easygoing

Excitable

Extroverted

Fearful

Follower

Good-Natured

Hardworking

Imaginative

Impatient

Impulsive

Introverted

Jealous

Leader

Likeable

Loner

Moody

Nervous

Often Blue

Persistent

Quiet

Sarcastic

Self-Confident

Self-Conscious

Serious

Shy

Stubborn

Any other words you would use?(Required)

People that know me think I am:(Required)

If they knew the "real me," they would know I am:(Required)

What I desire more than anything else in my life is:(Required)

What I fear most in life is:(Required)

The person I admire most in life is:....because?(Required)

Is there any other information you would like us to know?(Required)

Health

Rate your health(Required)

List all important (present or past) illnesses, injuries, or disabilities(Required)

Add as many rows as necessary

Name/Type

Date

Description

Weight Changes Recently?(Required)

If yes, what have you lost/gained?

Since (approximate date)?

Please list any medication(s) you are presently taking:(Required)

Add as many rows as necessary. Mark N/A if you are not taking any medications at this time.

Name

Strength

Dose

Have you ever used any drugs for other than medical purposes?(Required)

If Yes, please explain:(Required)

Have you ever had any counseling before?(Required)

If Yes, please explain:(Required)

Where/With Whom?(Required)

For what purpose?(Required)

Do you believe the issue was fully resolved? Explain.(Required)

Do you have any problems sleeping? If yes, please explain, including any methods used to address the issue:(Required)

Physician Information

We will not contact him/her without your permission via a Consent to Release Information Release Form

Physician(Required)

Physician Phone(Required)

Date of Last Medical Exam(Required)

MM slash DD slash YYYY

If determined necessary, are you willing to sign a release so your biblical counselor may write for medical or counseling reports from your current or previous providers?(Required)

Religious Background

Church Name(Required)

Frequency(Required)

Membership(Required)

Religious?(Required)

Belief in God?(Required)

Belief in Satan?(Required)

Occult?(Required)

Occult Explanation

Would you consider yourself a Christian?(Required)

What ministries/activities are you involved in at church?(Required)

Add as many rows as necessary. Mark N/A if you are not involved with anything at this time.

Name of Ministry or Activity

Your Role

Length of Time of Participation

Bible(Required)

Prayer(Required)

Do you have a regular time of devotions?(Required)

Describe your relationship with Christ:(Required)

Childhood Church(Required)

What was your religious experience as a child? What was your home environment like in regard to Christianity, the Bible, and the Church?(Required)

Explain any recent changes (if any) in your religious life.(Required)

Explain your spouse's religious background.(Required)

Other

Have you ever been arrested?(Required)

If yes, please describe the details of your arrest, including charges and date.

Have you ever suffered the loss of someone who was close to you?(Required)

If yes, please describe the details of your loss, including relationship and date.

Have you ever had a problem with alcohol or drug abuse (prescription or non-prescription)?(Required)

If yes, please describe the details including drug of choice, length of abuse, length of sobriety?

Have you ever had a severe emotional upset?(Required)

If yes, please describe.

Have you ever been abused as a child or as an adult (physical, sexual, emotional, etc.)?(Required)

If yes, please describe including relationship with the abuser, length of abuse, etc.

Is there anything else you would like us to know?(Required)

Consent(Required)

I will download and read the welcome packet, letter, consent and description of advocates in biblical counseling on the following confirmation page and read it fully. I understand that having an advocate (explained in file) is not required, but extremely beneficial. I am NOT affirming here that I have read these files, just that I will prior to my first session.

Phone

This field is for validation purposes and should be left unchanged.