Thank you for your interest in Applied Biblical Counseling. I look forward to the opportunity to get to know you, walk alongside you, and share with you the life-changing message of God’s Word.

Please take a few moments to fill out the following survey. This will help me get to know you better and allow us to use our time together more efficiently as we get started. Please be sure to fill out this survey as completely as possible.

Personal Identification

Full Name



Referred By


Education (last year completed)


Marriage and Family


Spouse's Age

How Long Employed

Work Phone

Length of Dating

Have either of you been previously married?

If so, to whom?

Have you ever been separated?

Have you filed for divorce?

Describe relationship to your father

Describe relationship to your mother


Describe your health

Date of last medical exam

Report of last medical exam

Physician’s name and address

Have you ever-used drugs for anything other than medical purposes?

If yes, please explain

Do you drink coffee?

If so, how much?

Do you drink other caffeine drinks?

If so, how many?

Have you ever had interpersonal problems on the job?

Have you ever seen a psychiatrist or counselor?

If yes, please explain


Denominational preference

Are you a member?

Do you believe in God?

Would you say that you are a Christian?

Or still in the process of becoming a Christian?

Explain any recent changes in your religious life

Problem Checklist

Check all that apply
AngerAnxietyApathyAppetiteBitternessChange in lifestyleChildrenCommunicationConflict (fights)DeceptionDecision MakingDepressionDrunkennessEnvyFearFinances

Briefly Answer The Following Questions

What is your problem (what brings you here)?

What are your expectations from counseling?

Download Printable Personal Data Inventory Survey