Counselee Intake Form
2:20 Online Biblical Counseling. Thank you for allowing me the opportunity to walk alongside you through biblical counseling. This intake form helps me understand your background, present circumstances, and the areas in which you are seeking help. Please complete all sections, including the confidentiality acknowledgments at the end.
About You
(This will remain confidentual)
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Email Address
*
example@example.com
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex
*
Please Select
Female
Male
Intersex
Prefer not to say
Other
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Engaged
Domestic Partnership
Other
Street Address
*
City
*
State
*
ZIP Code
*
Occupation
Employer
Highest Education Completed
How did you hear about 2:20 Online Biblical Counseling?
If someone referred you, who referred you?
Marriage and Family
Are you currently married?
*
Please Select
Yes
No
Separated
Widowed
Divorced
Spouse's Name
Spouse's Age
Spouse's Occupation
Wedding Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your spouse know you are seeking biblical counseling?
Please Select
Yes
No
Not sure
Not applicable
Would your spouse be willing to participate in counseling if appropriate?
Please Select
Yes
No
Maybe
Not sure
Not applicable
Have you and your spouse ever been separated?
Please Select
Yes
No
Not applicable
If yes, briefly explain the circumstances and approximate dates.
Have you been married previously?
Please Select
Yes
No
If yes, briefly describe any previous marriage(s).
Do you have children?
*
Please Select
Yes
No
Counseling Concerns
What is the primary concern that brings you to counseling?
*
How long has this been a concern?
What have you already tried to address this situation?
What would you most like to see change?
Past struggles
Depression
Anxiety
Anger
Grief or loss
Trauma
Substance use
Relationship conflict
Eating concerns
Self-harm
Other
Current struggles
Depression
Anxiety
Anger
Grief or loss
Trauma
Substance use
Relationship conflict
Eating concerns
Sleep problems
Work stress
Other
Which of the items above are affecting you most right now?
Counseling and History
Have you received counseling or therapy before?
*
Please Select
Yes
No
Unsure
Have you experienced significant emotional struggles in your past?
*
Please Select
Yes
No
Prefer not to say
If yes, briefly explain anything that would help me understand your history.
Physical Health
How would you describe your overall physical health?
*
Please Select
Excellent
Good
Fair
Poor
Other
Approximately how many hours do you sleep each night?
Have there been significant recent changes in your sleep, appetite, weight, or energy?
*
Please Select
Yes
No
If yes, please explain.
How often do you consume alcohol?
Please Select
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Other
Have you struggled with illegal drugs, misuse of prescription medication, or substance abuse?
*
Please Select
Yes
No
Prefer not to say
Church and Spiritual Background
Did you attend church growing up?
*
Please Select
Yes
No
Sometimes
Not sure
Church or denominational background
Do you currently attend a church?
*
Please Select
Yes
No
Sometimes
Church Name
City and State (church)
How regularly do you attend?
Please Select
Weekly
2-3 times a month
Monthly
A few times a year
Rarely
Not currently attending
Are you involved in a small group, Bible study, ministry, or other church activities? Please describe.
Would you be comfortable with me contacting your pastor or church leadership if it became helpful and you gave permission?
*
Please Select
Yes
No
Maybe
Please briefly describe your relationship with Jesus Christ.
How often do you personally read or study the Bible?
Please Select
Daily
Several times a week
Weekly
Monthly
Rarely
Never
How would you describe your prayer life?
Have there been any significant recent changes in your spiritual life?
Emergency Contact
Emergency Contact Name (other than spouse)
*
First Name
Middle Name
Last Name
Relationship to You
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Safety
Are you currently having thoughts of harming yourself?
*
Please Select
No
Yes
Prefer not to say
Are you currently having thoughts of harming another person?
*
Please Select
No
Yes
Prefer not to say
Is there anything about your current safety or circumstances that you believe I should know before our first conversation?
Confidentiality Acknowledgments
I have read and understand the confidentiality statement above.
*
I agree
I understand that biblical counseling is Christ-centered and will involve the use and application of Scripture.
*
I understand
I understand that submitting this form is a request for biblical counseling and does not itself establish an emergency-response service.
*
I understand
To the best of my knowledge, the information I have provided is accurate.
*
I agree
Signature
Typed Full Name
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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