Biblical Counseling Intake Form

Biblical Counseling Intake Form
Spouting off before listening to the facts isboth shameful and foolish. -Proverbs 18:13

Before we are able to offer wise biblical counsel, it is essential that we listen carefully to you and what is going on in your lives. In order to help us do that better, please carefully complete this inventory and turn it in to the PBCoffice at least three business days before your first appointment.

For couples, both individuals should complete this inventory independent of one another.
Your Name*

First NameLast Name
Birth Date:*
Sex:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*

Area CodePhone Number
Your Email*
example@example.com
Martial Status*
Education (last year completed/Degree Level)
Employer:
Position:
How Long Employed:
Give ten words that describe your personality:*

Marriage and Family

Please note that we does not provide “Professional” counseling.
If single, please describe your attitude toward your singleness:
If Married,

Please fill out the following about your spouse
Name

First NameLast Name
Birth Date:
Sex:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Employer:
Position:
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:

YesNo
To Whom:
Have you ever been separated from one another:

YesNo
Have you ever filed for divorce:

YesNo
Is your spouse supportive of counseling? Is he/she willing to be involved?

If you have children, please fill out the following about your children

Marriage and Family