• General Contact Information

    General Contact Information

  • Today's Date*
  • Gender*
  • Format: (000) 000-0000.
  • What type of counseling are you seeking?
  • Format: (000) 000-0000.
  • Education, Employment, & Religion

    Education, Employment, & Religion

  • Church Involvement (Please check all that apply.)*
  • Format: (000) 000-0000.
  • Do you pray to God?
  • Are you forgiven by God? Would you go to heaven if you died?
  • How frequently do you read the bible?
  • Do you read your Bible with your spouse and children?
  • Have you participating in...(Check all that apply)
  • Health & Lifestyle

    Health & Lifestyle

  • My health is...*
  • I consider myself...*
  • Have you ever had gender-reassignment surgery?*
  • Are you currently taking hormones or undergoing treatment to transition to another sex/gender?*
  • Have you had any of the following problems?
  • Do you have problems sleeping?*
  • Average Sleep Quality*
  • Recent Weight Changes
  • Have you experienced hallucinations?
  • Do you experience the feeling that people are watching you?
  • Suicidal Thoughts? (Check all that apply.)*
  • Suicidal Plans? (Check all that apply.)*
  • Suicidal Attempts? (Check all that apply.)*
  • Homicidal Thoughts? (Check all that apply.)*
  • Homicidal Plans? (Check all that apply.)*
  • Homicidal Attempts? (Check all that apply.)*
  • Use of Pornography
  • Have you ever had auditory or visual hallucinations? (Check all that apply.)
  • Have you ever been diagnosed with.. (Check all that apply.)
  • Marriage & Family

    Marriage & Family

  • Parents were.. (Check all that apply.)
  • Marital Status (Check all that Apply)
  • Have you ever been separated?
  • Have either of you filed for divorce?
  • Date filed for Divorce
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is your spouse currently filling out an application for counseling?
  • (Men Only) I could have children that I haven't met..
  • Final Questions

    Final Questions

  • Please choose any words that indicate your MAIN issues that bring you to counseling.*
  • From whom do you normally receive advice for problems? (Check all that apply.)

  • Consent to Counsel

  • Duty to Warn

  • Facts About Biblical Counseling

  • RGCC Appointment Policy

  • Should be Empty: