Counseling Request Form

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The Biblical Counseling Ministry Personal Data Inventory. Please complete this inventory carefully; your submission goes directly and confidentially to the Counseling Ministry team.

Prefer paper? You can also download the printable PDF and email the completed form to the Counseling Ministry.

Please complete this inventory carefully. All information is strictly confidential. (Question marks have been omitted)

Personal Identification

First Name Last Name Date of Birth Address Home Phone Business Phone Cellular Phone Email Address Age Sex Referred By Marital Status Education (last year completed) Employer Position Years Employed In case of an emergency, please contact Relationship Contact Number

Marriage and Family

Spouse Spouse's Date of Birth Spouse's Age Spouse's Occupation How long employed Date of Marriage Length of Dating Is your spouse willing to come for counseling Is he/she in favor of your coming for counseling Give brief statement of circumstances of meeting and dating Have either of you been previously married Did you file for divorce Have you ever been separated How many live births How many pregnancies have you had Information about your children: for each child list Name, Age, Sex, Living (Y/N), Years of Education, and whether they are a step-child

Family Background

Describe your relationship with your father Describe your relationship with your mother Number of siblings Your sibling order Do you live with anyone other than your parents Are your parents living Do they live locally

Health

Describe your health Do you have any chronic conditions List important illnesses / injuries / handicaps Date of last medical exam Report Physician's name and address Current medication(s) and dosage Have you had any menstrual difficulties (for women only)? Describe Do you experience tension, headaches, crying, or other symptoms prior to / after your menstrual cycle? Please explain Have you ever used drugs other than for medical purposes If yes, please explain Have you ever been arrested If yes, explain Do you drink alcoholic beverages Type, frequency and how much Do you drink coffee How much Frequency Other caffeine drinks / how much Do you smoke What

Work and Emotional History

Have you ever had interpersonal problems on the job Have you ever had a severe emotional breakdown? Please explain Have you ever seen a counselor or psychiatrist? Please explain Are you willing to sign a release of information so that your counselor may obtain social, mental health, or medical records

Spiritual

Denomination Church attending Church attendance per month Do you believe in God Do you pray Would you say you are a Christian or still in the process of becoming a Christian Have you been baptized How often do you read the Bible Explain any recent changes in your religious life Religious background of spouse Have you come to a place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven What was the basis for answering the way you did

Personality Information

Mark the following words which best describe you now.

Words that describe youActiveAmbitiousSelf-ConfidentPersistentNervousHardworkingImpatientMoodyImpulsiveOften-BlueExcitableImaginativeCalmSeriousEasy-GoingIntrovertLeaderShyHard-BoiledGood-NaturedSelf-ConsciousExtrovertLikeableQuietSubmissiveLonelySensitive

Other

Perception and Sleep

Have you ever felt people were watching you Do people's faces ever seem distorted Do you ever have difficulties distinguishing faces Do colors ever seem too bright Are you sometimes unable to judge distance Have you ever heard voices Do you ever see images or people Do you have difficulties hearing Do you have problems sleeping How many hours of sleep do you get each night

Personal Problem Checklist

Mark all that applyAddictionAngerAnxietyApathyAppetiteBitternessChanges in lifestyleChildrenCommunicationSleepDecision-makingDepressionDominatingDrunkennessEasily upsetEnvyFearFinancesGluttonyGuiltConflict (fights)Spousal AbuseImpotenceIn-lawsLonelinessLustMemoryMoodinessPerfectionismPridefulSexRebellionHealthHomosexualityDeceptionOther

If you marked Addiction or Other, please describe

Presenting Problem Questionnaire

Briefly answer the following questions.

1. What is the problem or concern that brings you here today? 2. What have you done about this problem? 3. What are your expectations from counseling? 4. Is there any other information we should know about?

I understand that the information I have provided is strictly confidential and will be reviewed only by the Biblical Counseling Ministry.