General Contact Information
Name
*
First Name
Last Name
Nickname or Preferred Name
Today's Date
*
Birthdate
*
Please select a month
January
February
March
April
May
June
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August
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Month
Please select a day
1
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Day
Please select a year
2026
2025
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current Age
*
Gender
*
Male
Female
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select what time zone you are located in.
Please Select
Eastern Standard Time
Central Standard Time
Mountain Standard Time
Pacific Standard Time
Other
Name of Parent or Legal Guardian
*
First Name
Last Name
Relationship to Parent or Legal Guardian
*
Parent or Legal Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Parent or Legal Guardian
example@example.com
Address of Parent or Legal Guardian
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred Here By?
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Education, Employment, & Religion
Highest Level of Education
GPA
How would you describe your learning style?
Please list any degrees, certificates, or special trainings you might have.
Where did you grow up?
Are you enrolled in school or college?
Are you employed?
Employer (Current or Last)
*
What was your position at current or last employer?
*
Number of Years Employed Here
*
Past Occupations (Employers & Positions)
Does your present work satisfy you? If not, please explain.
What religion do you associate with?
Denomination/Sect preference, if any?
Church Presently Attending (N/A, if not applicable.)
*
Church Involvement (Please check all that apply.)
*
Attend once per week
Attend multiple times per week
Attend once or twice a month
Attend occasionally
Don’t attend
Participate in Sunday School, Awana, or Youth Group
Member
Non-Member
Pastor/Elder or Other Church Leaders Name
*
First Name
Last Name
Pastor/Elder or Other Church Leaders Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reigning Grace will be reaching out to your pastor/elder. We understand that there are rare situations in which contacting your pastor/elder would not be helpful. If this is one of those situations, please explain the situation and why you would prefer we not reach out below. Please put N/A if this does not apply.
*
Does your pastor know of your decision to seek biblical counseling?
Please Select
Yes
No
Have you been/are you under church discipline?
Please Select
No.
Yes, I have been.
Yes, I am currently.
If yes to the above question, what church?
Other churches you have attended in the past.
Have you been baptized?
Please Select
Never
As an infant
After getting saved
Other
If you were baptized after infancy, what was your age?
Describe your own understanding of God.
What is your level of confidence in God?
Do you pray to God?
Never
Occasionally
Not Sure
Always
Other
Bible (Check all that apply)
I have my own Bible
I read my Bible daily
I read my Bible weekly
I read my Bible sometimes
I don’t read my Bible
I read my Bible with my parents, family, friends, or roommates
Are you forgiven by God? Would you go to heaven if you died?
Please Select
Yes
No
Not Sure
Do you have a relationship with Jesus Christ? If so, briefly explain how this came about.
What are God's expectations of you currently?
What is your greatest spiritual need at this point?
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Health & Lifestyle
My health is...
*
Very Good
Good
Average
Less than Average
Poor
I consider myself...
*
Heterosexual
Bisexual
Homosexual
Unsure
Have you ever had gender-reassignment surgery?
*
Yes
No
I'm considering it
Are you currently taking hormones or undergoing treatment to transition to another sex/gender?
*
Yes
No
I'm considering it
If yes to either of the above questions, please explain. If no to both, please put N/A.
*
Please list any current health issues.
Name & Facility of Primary Physician
Please list all current medications. Include prescriptions, over the counter, diet pills, laxatives, birth control pills, cold & allergy medicine, supplements, and pain relievers. List name and purpose of each.
Have you had any of the following problems?
Heart Problems
Liver Problems
Visual Problems
Sensory Distortion
Weakness
Problems Walking
Unusual Hair Loss
Parkinson's Disease
Blackouts
Amnesia
Constant Hunger
Headaches
Dizziness
Speech Problems
Lung Problems
Bulimia
Anorexia
Hallucinations
Change in Sex Drive
Seizures
Brain Tumor
Multiple Sclerosis
Nausea/Vomiting
Weight Change
Personality Change
Food Cravings
Allergies
Cancer
High Blood Pressure
Head Injury/Concussion
Kidney Problems
Stroke
Fatigue
Memory Problems
Tremors
Thyroid Disfunction
Diabetes
Hypoglycemia
Incoordination
Other
If you selected yes to any of the above, please explain.
What is your daily caffeine consumption?
Average Hours of Sleep per Night.
Do you have problems sleeping?
*
Yes
No
Average Sleep Quality
*
Good
Fair
Poor
Recent Weight Changes
Gained
Lost
If applicable, please explain your weight change.
Please list any previous surgeries (those which required anesthesia).
*
(Women Only) Have you had any menstrual difficulties? Do you experience tension, tendency to cry, or other symptoms to your cycle? Please explain.
Have you recently experienced a severe upset, nervous breakdown, or life-changing crisis?
Have you recently experienced a panic attack?
Did the crisis or panic attack require hospitalization?
Have you experienced hallucinations?
Yes
No
Do you experience the feeling that people are watching you?
Yes
No
Suicidal Thoughts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Suicidal Plans? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Suicidal Attempts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Have you had any close family/friend/coworker commit suicide? If yes, please explain the relation to you and when.
Homicidal Thoughts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Homicidal Plans? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Homicidal Attempts? (Check all that apply.)
*
Yes, recent.
Yes, current.
No
Are you currently experiencing physical abuse?
Are you currently experiencing mental abuse?
Are you currently experiencing emotional abuse?
Are you currently experiencing spiritual abuse?
Are you currently experiencing sexual assault or inappropriate touch?
Have you ever been involved in the abuse of another person?
Have you ever been involved in the molestation of another person?
Have you ever witnessed the abuse of another person, either child or adult? If yes, what forms of abuse did you witness?
In the past year, have you experienced the loss of someone who was close to you? If yes, please explain.
What was your age at your first exposure to pornography?
If you have been exposed to pornography, how were you first exposed?
Use of Pornography
Daily
Weekly
Monthly
Rarely
None
Are you sexually active?
No, never
Yes, currently
No, but I have been previously
What is your total number of sexual partners?
Have you used drugs for purposes other than medical reasons?
If so, what drugs? Is this current or past use?
Have you ever drank alcohol?
How many alcoholic beverages do you consume and how often?
Have you ever had alcohol-related problems or struggled to control drinking?
Have you ever struggled with non-chemical addiction? (Such as gambling, sexual activity, overeating, overworking, shopping, romance, pornography, the internet, sports or hobbies, cutting/self-mutilation, anorexia or bulimia, codependency, etc.)
If yes to the above question, please explain.
Do you currently use marijuana? If yes, is it for medical or medicinal purposes and how often?
Have you or others noticed any changes in your personality? (Anger, Mood Swings, Withdrawal)
Have you ever had auditory or visual hallucinations? (Check all that apply.)
Auditory (Past)
Auditory (Present)
Auditory (None)
Visual (Past)
Visual (Present)
Visual (None)
What are your strengths?
What are your weaknesses?
Have you ever been diagnosed with.. (Check all that apply.)
Bipolar Disorder
Schizophrenia
Depression
Borderline Personality
Anxiety
Generalized Anxiety Disorder
Panic Attacks
Eating Disorder
Obsessive Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Are you currently working with another counselor or therapist?
Please list all past & current counselors, therapists, psychologists, and psychiatrists you have had. Include any times you have been admitted to a mental health facility. (Include name, organization, location, beginning and end dates, initial reason for seeking help, and any diagnosis received along with medication prescribed.)
What was the outcome of the counseling/therapy? Was it helpful? If not, why?
Have you ever been arrested?
Have you ever been under a restraining order or ex parte?
Have you ever had a warrant? If yes, state circumstances & date.
Have you ever been imprisoned? If yes, date and length?
Are you on probation or parole? If yes, length of time?
Are you involved in any legal cases? If yes, explain your involvement.
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Marriage & Family
Name of Father
First Name
Last Name
Is your father living?
Father's Religion
Name of Mother
First Name
Last Name
Is your mother living?
Mother's Religion
Describe your parent's involvement in your life.
Parents were.. (Check all that apply.)
Never Married
Married
Separated
Divorced
Remarried
Your age when parents separated.
Your age when parents divorced.
Were you raised by anyone other than your biological parents?
Please list your siblings from oldest to youngest, including yourself. Mark step-siblings with an asterick (*).
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Final Questions
Please choose any words that indicate your MAIN issues that bring you to counseling.
*
Anger
Anxiety/Fear
Bitterness
Children
Conflict
Communication
Depression
Finances
Grief
Guilt/Shame
In-Laws
Health
Lifestyle
Lying
Self-Injury
Memories
Emotions
Marriage
Sex/Lust
Sleeping
Addictions/Habits
Eating Issues
Fatigue
Abuse/Violence
Major Changes
Moodiness
Impotence
Deception
Spousal Abuse
Homosexuality
A Particular Vice
Please write a quick summary of your main concerns. Indicate how long you have had these concerns.
*
What have you already done about these concerns? What have been the results?
*
Please describe any significant events related to your concerns.
*
What, if anything, do you fear?
*
What would you like us to do? What are your expectations and goals in coming here?
From whom do you normally receive advice for problems? (Check all that apply.)
Friend
Pastor
Neighbor
Relative/Family
Counselor/Therapist
Other
Were you referred here by someone? (Name & Relationship)
Was your involvement in counseling placed on you as a requirement? If yes, please explain.
Is there any other information we should know?
*
Consent to Counsel
Duty to Warn
Facts About Biblical Counseling
RGCC Appointment Policy
Signature
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