Detailed Intake
1948 N Plaza Dr. Rapid City, SD 57702
Please fill out this questionnaire as completely as possible. Your information will be kept confidential.
Today's Date
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Month
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Day
Year
Date
Basic Information
Name
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First Name
Last Name
M/F
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Please Select
Male
Female
Birth date
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Month
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Day
Year
Date
Age
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this location?
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Number of times moved in last 5 years
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Main Phone
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Email Address
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example@example.com
Educational & Vocational
Highest grade completed
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College (If attended)
Degree(s)
Vocational training
Military Service: Branch
Years served
Employer
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Job Title
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How long have you been at this job?
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How many jobs have you had in the last 5 years?
*
Reasons for Leaving
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Marital Data
Status
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Please Select
Single
Never married
Engaged
Married
Separated
Divorced
Widowed
If Applicable: Spouses name
Age
*
# of times married
Occupation
*
Does your spouse know you are coming to receive counseling?
Yes
No
Children
Rows
Name
Step-Child?
Age (if living)
HealthCondition
At Home?
Age of Death?
Cause of Death
1
2
3
4
5
6
Family History
Rows
Age (If living)
Health Condition
Age at Death
# times Married
Alcohol/Drug abuse?
Father
Mother
Step-father
Step-Mother
Spouse's Father
Spouse's Mother
Spouse's Step-Father
Spouse's Step-Mother
Please evaluate the relationship between you and your parents while growing up. Check all that apply.
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Rows
Father
Mother
Step-Father
Step-Mother
Had the greatest effect on you?
Usually did the disciplining
Was away a great deal?
You identified with the most?
You were close to?
Major conflicts with?
More dominant personality?
Abuse drugs and/or alcohol?
Physically abused you?
Was a workaholic?
How many siblings do you have?
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Were you?
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Please Select
Oldest
Middle
Youngest
How many siblings does your spouse have?
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Was your spouse?
*
Please Select
Oldest
Middle
Youngest
How would you describe your childhood?
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Health Survey
Are you presently under a physicians care?
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Date of last visit
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Month
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Day
Year
Date
Physicians name?
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Personal physician if different?
*
For what condition(s) are you being treated?
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Date of your last complete physical examination?
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Month
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Day
Year
Date
What, if any, medications are you currently taking? (give dosage and reason for medication)
*
Do you have a history of drug use?
Yes
No
Current use?
Yes
No
Frequency?
*
Type of drugs?
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Have you had a history of excessive use of alcohol?
Yes
No
Do you presently?
Yes
No
Have you been hospitalized for emotional problems?
Yes
No
If yes, give date(s) and reason(s)?
Have you taken medications for emotional problems?
Yes
No
If yes, please list?
Have you experienced any recent significant weight loss or gain?
Yes
No
Please list any other medical conditions.
Have you previously received counseling?
Yes
No
If yes, was it helpful?
Yes
No
If you have previously received counseling complete the following?
Rows
Dates?
With whom?
Reason(s)?
Reason for stopping?
Previously received counseling?
Religious Background
Did you attend church as a young person?
Yes
No
Denomination?
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How often did you attend?
*
Was it a positive experience?
Yes
No
Do you attend church now?
Yes
No
If yes, which church?
*
How often do you attend?
*
Is it a positive experience?
Yes
No
Have you made the great discovery of knowing Jesus Christ personally?
Yes
No
Unsure
Do you have a regular time of personal Bible Study?
Yes
No
Unsure
How much have you studied the Bible?
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Personal History
Have you ever experienced child or spousal abuse?
Yes
No
Other
Have you ever experienced rape, incest or sexual molestation?
Yes
No
Have you been involved in an out-of-wedlock pregnancy?
Yes
No
Have you ever had an abortion?
Yes
No
Have you ever attempted suicide?
Yes
No
Has anyone close to you committed suicide?
Yes
No
If yes, when?
Rows
Have a high need for achievement?
Have a high need for approval?
Be a workaholic?
Do you have a tendency to:
Do you struggle with relationships? If yes, please explain.
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What has been your exposure to pornography? Explain:
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Has screen time/phone usage caused conflict in any relationships? Explain:
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Summarize where you spend the most time on your phone (most utilized apps):
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Are finances a recurring problem?
Yes
No
Other
Do you have any overwhelming fears? If yes, please explain.
Have you ever had any non-Christian religious or spiritual experiences? (cult involvement, daily horoscope, psychic experiences, etc) If yes, please explain.
Have you ever been involved in criminal activity?
Yes
No
List any arrests and convictions with the dates:
What has been your greatest disappointment? Please describe.
*
Explain briefly what you believe your problem is:
*
What do you want the Biblical counseling process to accomplish?
*
Why did you choose Christian Life Ministries? Other Comments?
*
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