Premarital Counseling Form

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The Premarital Counseling Personal Data Inventory. This questionnaire is to be answered individually and honestly; 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.

This questionnaire is to be answered individually and honestly. All information is strictly confidential. Please read all questions carefully, as some contain two or more parts.

Counseling Registration and Commitment

First Name Last Name Phone Email Address Address Business Phone Sex Birth Date Age

Status (check all that apply to your situation)Never MarriedDivorcedSeparatedLiving with fianceMarriedGoing Steady/DatingEngagedWidowed

Your fiance(e)'s Full Name Fiance(e)'s Age How soon do you plan to marry? Have you ever practiced or participated in homosexual or bisexual relations? Why are you getting married? What are the reasons you want pre-marital counseling? (a, b, c) We will need 11 to 14 counseling sessions, or more. Are you willing to make time to complete the counseling? If no, explain You will be given assignments which consist of reading, studying, giving information, and honest discussions. Are you committed to doing this? If no, explain Do you understand that your choice of a marriage spouse will determine the success of your marriage and that pre-marriage counseling is only an aide, but not a guarantee of success?

Please note: you will have to pay for books, booklets, and materials used in counseling.

Dating Data

1. How soon do you plan to marry? 2. When did you first meet one another? Where? 3. How did you meet? 4. How long have you known each other? 5. How long have you dated? 6. How long have you been discussing marriage? 7. How long have you been officially engaged? 8. Have you been engaged before? If yes, how many times? What was the outcome of the relationship(s)? 9. Were you going steady with anyone within six (6) months before you started going steady with your fiance? Explain 10. Have you and your fiance ever broken up? If yes, for what reason? 11. Why do you think this is the right time to get married? 12. Do your parents approve or disapprove of your marriage? Explain 13. Define what you mean when you say you love your fiance. 14. Why are you getting married? Be specific. 15. What do you expect to get out of this marriage? 16. What do you expect to give in the marriage? (a, b, c, d) 17. What will be the advantages of you getting married rather than being single? 18. What are some of the conflicts you have with your fiance? (a, b, c) 19. What has been the most serious problem in your relationship? If it has been solved, how? 20. What has been the worst disappointment you have experienced in the relationship so far?

Health Data

1. Rate your health 2. List all present or past illnesses, injuries, or handicaps 3. Date of last medical examination Results 4. Are you presently taking medication? If yes, what? And for what health condition? 5. Are you using or have been using such drugs as marijuana, cocaine, heroin, or others? If yes, explain 6. Do you know if you can not give birth to children? (Females) Explain 7. Who is your doctor? Name Doctor's Phone 8. Have you ever had any counseling or psychotherapy before? If yes, what was the problem? List counselor or therapist and dates

Personal Data

1. Are you a parent of children from a previous relationship? 2. Have you ever been arrested? If yes, what were the charges or circumstances? 3. What is your life's ambition? 4. What is the worst thing that ever happened to you? 5. Do you have any type of venereal disease? If yes, explain. 6. Do you have any fears or concerns about having sex?

7. Have you experiencedIncestHomosexual/LesbianMolestedRapedIndecent ExposurePornographyMasturbation

8. What areas do you have questions concerning sex? 9. Are you a virgin? If no, do you have any guilt about your past sexual experience? If yes, explain 10. Does your fiance know that you're not a virgin? 11. In what way do you think your sexual experiences will affect your marriage? 12. What are your views about abortion? 13. Are you experiencing sexual temptation for your fiance? Explain

Education and Occupation

1. Education (last year completed / grade) Degree and Major Other training and year completed 2. Do you have any future educational plans? Explain. 1. Are you employed? If yes, full or part-time? 2. What type of work do you do on this job? 3. If unemployed, how long? How much time have you been spending in trying to obtain a job weekly? What are your occupations or trades? (a, b, c) 4. Have you ever been asked to leave a job? If so, for what reason? 5. Where do you presently work? How long have you been employed there? How do you like it? 6. What is your current salary? 7. What are your future occupational plans? 8. If you are a woman who works, do you intend to work after marriage? Explain. 9. What do you intend to achieve in the next 10 years in your occupation? 10. In any way do you foresee your career affecting your marriage in a negative way? If so, how?

Religious and Spiritual Data

1. Denominational or religious preference 2. Church attendance per month 3. Church attended in childhood? 4. Do you consider yourself a religious person? 5. Do you believe in God? 6. Do you pray to God? 7. Are you saved? If yes, when 8. How frequently do you read the Bible? 9. What one word would best describe your overall spiritual life / your present spiritual experience? 10. How would you describe your spiritual growth during the past year? 11. List any Bible instruction you have received (a through f) 12. Name of Church Church Address Name of Pastor 13. Specifically describe your involvement in your church, if any. 14. Are your parents Christians? Explain. 15. How would you describe your parents' spiritual lives while you were growing up?

About You

1. How would you describe your personality? 2. How do you react when you are angry? 3. What are some of your past and present fears? 4. Do you ever worry? If yes, please explain. 5. Have you ever had hallucinations? If yes, please explain. 6. Do you have problems sleeping? If yes, please explain. 7. What is the most difficult thing you had to forgive someone else for? 8. What do you like most about yourself? 9. What do you dislike most about yourself? 10. What do you like most about your fiance? 11. What do you like least about your fiance?

12. Check the words that best describe youAmbitiousSelf ConfidentPersistentNervousHardworkingImpatientImpulsiveMoodyOften BlueExcitableCalmSeriousEasy-GoingShyGood NaturedIntrovertExtrovertLikeableLeaderHelper of OthersHardFlexibleSubmissiveSelf-ConsciousSensitive

Add your own 13. How has knowing your fiance changed your life? 14. Is there anything else you wish to add that would enable us to better know you?

Reason for Choosing My Mate

List seven qualities you had in mind, that would be desirable, in the person you would choose to marry. (1-7) List ten reasons which led to your decision to marry your fiance. These may include attitudes, personality, traits, physical attractions, etc. (1-10) List your personal specific goals for your marriage. These should include more than broad goals such as 'To have a marriage that honors the Lord.' Think through the smaller nitty-gritty goals that make such a broad goal possible. (1-5) List at least five contributions that you bring to this marriage that will help to make it work (gifts, skills, character traits, experience, etc.). (1-5)

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