Would you be willing to allow a counselor in training to observe your counseling sessions? *
Are you in a significant relationship other than marriage? Explain and include how long: *
Children's Name(s); Age; Sex; Are they Living?; By Previous Marriage?
Have you ever been separated before? *
Has either of you ever considered or filed for divorce? *
Have you been married before? *
Is your spouse in favor of your coming to counseling? *
Is your spouse willing to come to counseling (if needed)? *
Medicine
List all prescriptions and over-the counter medications you are currently taking (include diet pills, laxatives, birth control pills, cold and allergy medicines, aspirins, etc) and the reason for taking them:
List all important present or past illnesses, physical difficulties, injuries or handicaps:
Have you used drugs for other than prescribed medical purposes? *
Have you used more than the prescribed amount of any medication? *
How much of the following types of beverages do you consume daily or weekly? *
Alcohol:
Have you ever experienced hallucinations, seen distorted faces, or heard voices? *
Have you ever had a severe emotional upset? If so, please explain: *
Have others noticed any significant changes in your emotional or mental state, memory, or work abilities? *
Are you willing to sign a release of information so that your counselor may request any counseling and medical information that might be helpful? *
Were you raised by both biological parents? *
Rate your parent's marriage: *
Are/were your parents divorced? *
If yes, explain briefly when, and the basic circumstances:
Describe your relationship with your mother: *
Describe your relationship with your father: *
Describe your relationship with your siblings: *
Excessively authoritative/ Very high control
Excessively permissive/ Too low control
Generally balanced leadership/ Authority
Manipulative (selfish, angry, guilt trip)
Rules/Instructions without relationship
Disengaged/Excessively preoccupied
Caring Involvement/Instruction
Perfectionistic/Very performance driven
Check all the following that best describe the predominant atmosphere(s) in your home as a child: *
Was there any substance abuse in your family? *
Other than your parent(s), describe people in your life who have had a significant influence in your life (positive or negative): *
Has there been any abuse in your past? *
Have you ever seen a psychologist, psychiatrist or received counseling before? *
If yes, list counselor(s) and dates.
What was the outcome? Was it helpful?
Do you carry significant guilt? *
Have you ever been arrested? *
If yes, describe the circumstance:
Describe any recent, significant event(s) in your life (ex: job loss, birth, death, successes, etc): *
Church/religious experience as a child (denomination and length of time): *
Church/religious experience as an adult (denomination and length of time): *
Do you attend a local Christian church? *
Have you been baptized? *
Are you part of a small group? *
Do you attend church with your spouse? *
Do you consider yourself as "saved"? *
Does your spouse consider himself/herself as "saved"? *
Have you come to the place in your spiritual life where you know with certainty that you would enter heaven after death? *
If you were to die and stand before God and He asked you why He should permit you to enter heaven, how might you respond? *
Explain recent changes in your spiritual life, if any:
How often do you pray to God? *
How often do you read the Bible? *
Do you regularly give financially to the church/God's work? *
Abuse (sexual, physical or verbal)
Select… 1 2 3
Conflict (Fights)
Select… 1 2 3
Decision making
Select… 1 2 3
Drastic change in life circumstances/life style
Select… 1 2 3
Envy or Jealousy
Select… 1 2 3
Mental Confusion
Select… 1 2 3
Poor concentration
Select… 1 2 3
Procrastination
Select… 1 2 3
Same sex attraction
Select… 1 2 3
Sex (lust, impotence...)
Select… 1 2 3
Are you seeking personal counseling or marriage counseling? *
Do you have flexibility with your schedule? *
Submit
