• Personal Data Information Form for Biblical Counseling

    This form must be completed in full before a counselor is assigned. All information is confidential.

  • Identification Data

  • Format: (000) 000-0000.
  • Gender

  • Birthdate Age

  • Referred by:

  • Health Information

  • Rate your helath

  • Height Weight    
    Weight changes recently?      

  • Date of last medical exam Report

  • Are you currently taking medication?
  • Have you used drugs other than for medical purposes?
  • Have you ever been arrested?
  • Are you willing to sign a release or information form so that your counselor may write for social, psychiatric, or medical reports?
  • Have you recently suffered the loss of someone who was close to you?

  • Education

  • Marriage and Health

  • Marital Status
  • Format: (000) 000-0000.
  • Would your spouse be willing to come in for counseling?
  • Have you ever been separated?
  • Have either of you filed for divorce?

  • Your ages when married? Husband Wife

  • Religious Background

  • Do you consider yourself a religious person?
  • Do you believe in God?
  • Do you believe Satan exists
  • Have you ever dabbled with Occult? )Seances, devil worship, witchcraft, etc.
  • Do you pray to God?
  • Would you say you are a Christian?
  • How often do you read the Bible?
  • Do you have regular devotions?

  • Please answer the following questions:

  • Should be Empty: