biblical counseling.

BIBLICAL COUNSELING QUESTIONNAIRE

Personal Information

First & Last Name:

Birthdate:

Address:

Home / Cell Phone:

Work Phone:

Email:

Education (last year completed):

Employer:

Position:

How Long Employed:

Marriage & Family

Spouse Name:

Spouse Birthdate:

Spouse Occupation:

How Long Employed:

Date of Marriage:

Length of Dating:

Give a brief statement of circumstances of meeting and dating:

Have either of you been previously married:

Yes

No

Have you ever been separated:

Yes

No

Have either of you ever filed for divorce:

Yes

No

Information about Children: (age, sex, living or deceased, biological or stepchild, relationship to father, & relationship to mother)

Health

Describe Your Health:

Do you have any chronic conditions:

Yes

No

Explain:

Date of Last Exam:

Report:

Current Medication(s) and Dosage:

Have you ever used drugs for anything other than medical purposes:

Yes

No

If yes, please explain:

Have you ever been arrested:

Yes

No

Do you drink alcoholic beverages:

Yes

No

If so, how frequently and how much:

Do you drink coffee:

Yes

No

If so, how much:

Do you drink other caffeinated drinks:

Yes

No

If so, how much:

Do you smoke:

Yes

No

If so, what product, how much, & how often:

Have you ever had interpersonal problems at work? Please explain:

Have you ever had a severe emotional upset? Please explain:

Have you ever seen a psychiatrist or counselor? Please explain:

Spiritual

Denominational Preference:

Church Attending:

Member:

Yes

No

Do you believe in God:

Yes

No

Do you pray:

Yes

No

Would you say you're a christian, or still in the process of becoming a christian:

Yes

No

Have you ever been baptized:

Yes

No

How often do you read the Bible:

Never

Occasionally

Often

Daily

Explain any recent changes in your religious life:

Women Only

If your husband willing to come for counseling:

Yes

No

If your husband in favor of you coming:

Yes

No

If not, please explain:

Problem Checklist

Briefly Answer The Following:

1. What is the problem (what brings you here)?

2. What have you done about the problem?

3. What are your expectations for counseling?

4. Is there any other information that we should know?

Moriah Church Biblical Counseling

Policies and Procedures/

Consent to Counseling

BIBLICAL COUNSELING CONSENT FORM

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CALL

217-609-0800

EMAIL

moriahbiblicalcounseling@gmail.com