Personal Intake Form Name * First Name Last Name Date MM DD YYYY Gender * Male Female Your Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Occupation Emergency Contact Person Marital Status (check all that apply) Single Dating Engaged Married Divorced Separated Widowed Remarried Living together and unmarried My Health Is Very Good Good Average Less Than Average Poor All current medications (prescription and over-the-counter) Are you currently working with any other counselor or therapist? Yes No Have you ever participated in counseling or therapy in the past? Yes No Religious Background What religion do you associate with? Describe your current involvement, if any: Previous involvement in any other religious groups: Describe your understanding of God % Level of confidence in God Do you pray to God? Never Occasionally Often Are you forgiven by God? Would you go to Heaven if you died? Yes No Not Sure How frequently do you read the Bible? Never Occasionally Often Do you have a relationship with Jesus Christ? If so, how did this relationship come about? Please explain any recent changes in your religious life Briefly answer the following questions: What brings you to counseling? Please write a quick summary of your main concerns. What have you already done about these concerns? What have been the results? What are your expectations and goals in receiving biblical counseling? Is there any other information that we should know? Were you referred here by someone? If So, what is your relationship to the person who referred you? Thank you! We will be in touch soon. Please make sure you also fill out the informed consent form.