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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?