Counseling Intake Form
Thank you for choosing to begin your Biblical Counseling journey with me. This intake helps me understand your story, spiritual background, and current concerns so care may be tailored wisely, compassionately, and biblically. Please answer honestly and as thoroughly as you are comfortable.
Section 1:
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status:
Single
Married
Divorced
Widowed
Separated
Spouse's name (if applicable):
Children's Names and Ages (if applicable):
Section 2:
Spiritual Background
Do you consider yourself a follower of Jesus Christ?
Yes
No
Unsure/Exploring
Briefly describe your salvation or faith journey:
Church you currently attend (if any):
How often do you attend services or participate in church life?
Are you currently involved in a small group, Bible study, or discipleship relationship?
Yes
No
Section 3:
Presenting Concerns
What are the primary reasons you are seeking counseling at this time?
How long have these concerns been present?
Have you received counseling in the past?
Yes
No
If yes, what was helpful or unhelpful?
What are your hopes or goals for counseling?
Section 4:
Current Symptoms & Functioning
Please check any symptoms you are currently experiencing:
Anxiety or panic
Depression or hopelessness
Excessive worry
irritability or anger
Mood swings
Difficulty sleeping
Nightmares or intrusive memories
Fatigue or low energy
Loss of interest or motivation
Social withdrawal
Guilt or shame
Difficulty concentrating
Appetite changes
Physical symptoms without clear medical cause
Thoughts of self harm or suicide
Compulsive behaviors or addictions
Have you ever been diagnosed with a mental health or medical condition?
Yes
No
If yes, please describe:
Are you currently taking any medications?
Yes
No
If yes, please list them and what they are prescribed for:
How are these concerns affecting your daily functioning, work, relationships, or spiritual life?
Section 5:
Family of Origin & Life History
Describe your family growing up (parents. siblings, home environment):
Were there significant traumas, losses, neglect, abuse, or chronic conflict in your home?
Yes
No
If yes, please explain (as you are comfortable):
How were emotions handled or expressed in your family?
What role did faith, church, or religion play in your household?
Describe your relationship with your parents or caregivers (past and present):
Have any family members struggled with mental illness, addiction, or significant relational dysfunction?
Yes
No
If yes, please explain:
SECTION 6:
TEMPERAMENT
Temperament refers to the inborn design God has given you that shapes how you relate, decide, and connect emotionally. We utilize the Arno Profile System (APS) developed by the National Christian Counselors Association to identify temperament in three areas: Inclusion – social orientation; Control – decision-making and leadership; Affection – deep emotional relationships. This understanding allows counseling to be more precise, compassionate, and biblically tailored.
Have you ever taken a temperament test?
Yes
No
If yes, which one or through which provider?
Submit
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