Intake Form

West Center Biblical Counseling

West Center Biblical Counseling Intake Form

Personal Information

Name:*

Today's Date:*

Address:*

Phone Number*( ) -

Email*

Occupation:*

How long employed at current occupation?*

Sex:*

Male

Female

Birth date*

Age:*

Referred to West Center Biblical Counseling by:*

Spouse Information

Please leave the fields blank if you aren't/haven't been married and move to the children section.

Name of Spouse:

If applicable.

Spouse's Age:

If applicable.

Spouse's Religion:

If applicable.

Is your spouse willing to come for counseling?

Yes

Have you ever been separated?

Yes

If you have been separated, from when to when?

Please answer as from ___________ to _______________

Have either of you filed for divorce?

Yes

If divorce has been filed, when?

Please approximate if you don't know the exact date.

Date of marriage:

Give a brief description of any previous marriages.

Children

Please leave fields blank if you don't have children and move to the family information section

Child #1

Child #1's Name

Child #1's Age

Child #1's Sex

Male

Female

Is Child #1 Married?

Yes

Is Child #1 living with you?

Yes

Child #2

Child #2's Name

Child #2's Age

Child #2's Sex

Male

Female

Is Child #2 Married?

Yes

Is Child #2 living with you?

Yes

Child #3

Child #3's Name

Child #3's Age

Child #3's Sex

Male

Female

Is Child #3 Married?

Yes

Is Child #3 living with you?

Yes

Child #4

Child #4's Name

Child #4's Age

Child #4's Sex

Male

Female

Is Child #4 Married?

Yes

Is Child #4 living with you?

Yes

Child #5

Child #5's Name

Child #5's Age

Child #5's Sex

Male

Female

Is Child #5 Married?

Yes

Is Child #5 living with you?

Yes

Child #6

Child #6's Name

Child #6's Age

Child #6's Sex

Male

Female

Is Child #6 Married?

Yes

Is Child #6 living with you?

Yes

If you have any more children, please list them here.

Family Information

If you were raised by anyone other than your parents, please briefly explain.*

How many older brothers do you have?*

How many older sisters do you have?*

How many younger brothers do you have?*

How many younger sisters do you have?*

Health Information

Recent weight changes?*

Yes, gained.

Yes, lost.

List all important past illnesses, injuries, or handicaps.*

Approximate date of last medical exam?*

What was the outcome of your last medical exam?*

Current physician:*

City and State of current physician.*

Are you presently taking medication?*

Yes

If you are presently taking medication, what medications?

Have you ever used drugs other than for medical purposes?*

Yes

If you have ever used drugs other than for medical purposes, what drugs?

Have you ever had a severe emotional incident or season? If so, please explain.*

Do you drink alcohol?*

Yes

If you do drink alcohol, how often and how much?

Do you smoke?*

Yes

Religious Background

Religious/Denominational preference?*

Are you baptized?*

Yes

Current church?*

Are you a member of your current church?*

Church attendance per month:*

Childhood church or religion?*

Do you believe in God?*

Yes

Do you believe you are saved?*

Yes

Unsure

Do you pray to God?*

Do you read the bible?*

Explain where you are with God in your own words.*

Personal History

Have you ever been to a therapist or counselor before?*

Yes

If you answered yes to the previous question, please list the counselor/therapist, approximate dates, and whether it was helpful or not helpful.

Do you have problems sleeping?*

Yes

If yes, please explain.

What is the problem that brings you in today?*

Have you tried to address the problem?*

What do you hope to accomplish in counseling?*

Scheduling

Counseling takes place on Thursdays between 3:00 PM and 8:00 PM at West Center Baptist Church. Please check the times you are available on Thursdays.*

3:00

4:00

5:00

6:00

7:00

Please leave this field blank.

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