Biblical Counseling Ministry

Counselor
Date

Personal Information
Name (First, Last)
Age
Gender
Address
City
Zip
Home Phone
Cell Phone
Work Phone

Family Information
Marital State Single Married Separated
Divorced Widowed
Spouses Name
Married previously? Yes No If Yes?
Names and ages of children:
Have there been any deaths in the family in the past two years?

Employment Information
You Time
Spouse (if applicable) Time

Spiritual Information
Do you believe in God?


Do you pray to God?


Do you read the Bible?
Is Calvary Houston your home church? Yes No How long?
How many times per month do you attend church?
Have you received Jesus Christ as your Lord and Savior?
If yes, when?
Have you been baptized in water since you received Christ?
Have you been involved in any cults or occult practices?
If yes, explain
Do you know for certain if you died tonight that you would go to heaven?
What is the basis for answering the above question as you did?

Health Information:
Please list any medication(s) you are presently taking:?
Have you had any professional counseling before?
Have you or do you now use alcohol or drugs?
Have you had a severe emotional upset in the past 3 years? If yes, when?

Please check any of the following general problem areas you are experiencing:
Not resolving conflicts Credit or debt problems Selfishness
Conflicts over decision making Unrealistic expectations Possessiveness or jealousy
Interference from in-laws Pornography or
gambling abuse 		Sexual frustration
Drug or alcohol abuse Unforgiveness Anger
Adultery/fornication Lack of involvement or discipline problems with the children Over commitment outside the home: job, sports, etc.
Family conflicts Lack of communication Struggling in your Christian walk

Briefly Answer the Following Questions:
Is there one problem which has motivated you to make this appointment today?
What are you expecting to receive from this counseling?
On a scale from 1 to 10 rate your willingness (10= very willing, 1= not willing)
Are you willing to come to God, fully surrender, and receive His abundant life?
Are you willing to let the Word of God teach you how to respond correctly to your spouse/situation?
Are you willing to do more than talk?
Are you willing to do what God requires of you?
Are you willing to deal with yourself and your own faults first?
I understand that I am not seeking nor receiving paid, secular counseling, but I am asking for Biblical, spiritual advice. I also understand that the confidentiality of my disclosures will be maintained by the Counselor and the Pastoral Staff of Calvary Houston. I understand that all Counselors will act as a conduit to the Pastoral Staff. I understand that the privilege of confidentiality is an individual privilege. The privilege may be waived should the counselee discuss the privileged matters in the presence of third parties or discuss the content of the counseling with a third party after the counseling session, thus disclosing the content of the counseling session into the public domain. The discussion of counseling content with a person not a part of the counseling ministry may act as a waiver of privilege.
Name (placing your name in this box confirms you are seeking Biblical Counseling)
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