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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 intake 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 your information as completely as possible.

Personal Identification

Full Name*



Referred By


Education (last year completed)


Birth Date

Zip Code*


Marital Status*

Phone Number


Years at Employer


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

Church attending

Church attendance per month

Do you pray?

Have you ever been baptized?

How often do you read the Bible?

Problem Checklist (Check All That Apply)

AngerAnxietyApathyAppetiteBitternessChange in LifestyleChildrenCommunicationConflict (Fights)DeceptionDecision MakingDepressionDrunkennessEnvyFearFinances
GluttonyGuiltHealthHomosexualityImpotenceIn-lawsLonelinessLustMemoryMoodinessPerfectionismRebellionSexSleepWife AbuseA ViceOther

Marriage and Family

Spouse’s Name

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

Birth Date

Spouse’s Occupation

Home Phone

Date of Marriage

Give a brief statement of circumstances of meeting and dating

Information about Children: Name: Age: Sex: Living: Year Ed.: Step-Child:

Number of sibling(s)

Your sibling order

Did you live with anyone other than parents?

Are your parents living?

Do they live locally?


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

Do you have any chronic conditions?

If so, what conditions?

List important illnesses and injuries or handicaps

Current medication(s) and dosage

Have you ever been arrested?

Do you drink alcoholic beverages?

If so, how frequently and how much?

Do you smoke?

If so, what do you smoke?

Smoking frequency

Have you ever had a severe emotional upset?

If yes, please explain

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records?

Briefly Answer The Following Questions

What is your problem (what brings you here)?

What are your expectations from counseling?

What have you done about the problem?

Is there any other information that we should know?