Biblical Counseling Intake Form (Adult)

BRIEFLY ANSWER THE FOLLOWING QUESTIONS
1. Please describe the current problem for which you are seeking Biblical counseling:
2. What have you attempted to do to alleviate the problem (if anything)?
3. What do you hope to achieve through Biblical counseling process? Briefly list two to three goals:
4. Have you sought other outside help? if so, from whom?
5. Are you a believer in Jesus Christ ?

YesNo
6. Please explain the Gospel as you understand it in the space provided below:

CHURCH AFFILIATION
1.Are you a member of a local church?

YesNo
2. If so, what is the name of the church you attend:
How long have you attended this church?
3. Are you actively involved in your church?

YesNo
4. Do you have a person/people to whom you are accountable at your church?

YesNo
5. Do you believe being an active part of a community of believers is important to reaching your goals in biblical counseling? Why? Why not?
6. How did you hear about Choice Biblical Counseling Ministry?

EMERGENCIES

Please provide contact information of someone we may call in case of an emergency:
EMERGENCY CONTACT:

First NameLast Name
RELATIONSHIP:
Phone Number
Please enter a valid phone number.
If you are unable to reach us in a timely manner, you should contact your physician, a local emergency room or the local police department when necessary and appropriate. It is your responsibility to seek the appropriate resources in emergency situations. By your signature below, you indicate that you have read and understood this statement, and any questions about this statement were answered to your satisfaction. You also indicate that you have received a copy of this statement for your records. By our signature it verifies the accuracy of this statement and acknowledges my commitment to conform to its specifications.
Client Name

First NameLast Name
Signature

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Date

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Date
Biblical Counselor Name (Printed)
Signature of Biblical Counselor

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Date

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Date
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BRIEFLY ANSWER THE FOLLOWING QUESTIONS